Provider Demographics
NPI:1629422423
Name:PACHECO, PARIS ETHAN (MD)
Entity Type:Individual
Prefix:
First Name:PARIS
Middle Name:ETHAN
Last Name:PACHECO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PARIS
Other - Middle Name:ETHAN
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:600 GRESHAM DR FL 5
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-388-3198
Mailing Address - Fax:757-388-4242
Practice Address - Street 1:600 GRESHAM DR FL 5
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3198
Practice Address - Fax:757-388-4242
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101267142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program