Provider Demographics
NPI:1609205764
Name:PACHECO, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PACHECO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 SUFFOLK WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-7708
Mailing Address - Country:US
Mailing Address - Phone:707-344-4800
Mailing Address - Fax:
Practice Address - Street 1:275 BECK AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6804
Practice Address - Country:US
Practice Address - Phone:707-784-8679
Practice Address - Fax:707-421-7484
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA794401163W00000X
CA80245163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse