Provider Demographics
NPI:1689032534
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 1:606 24TH AVE S, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:MINEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454
Mailing Address - Country:US
Mailing Address - Phone:612-659-8689
Mailing Address - Fax:612-659-8690
Practice Address - Street 1:606 24TH AVE S STE 200
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1437
Practice Address - Country:US
Practice Address - Phone:612-659-8689
Practice Address - Fax:612-659-8690
Is Sole Proprietor?:No
Enumeration Date:2016-02-07
Last Update Date:2016-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program