Provider Demographics
NPI:1699842021
Name:PICHARDO, MARLO (PAC)
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:
Last Name:PICHARDO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MARLO
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:404 N HORTON ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-6541
Mailing Address - Country:US
Mailing Address - Phone:208-466-9292
Mailing Address - Fax:
Practice Address - Street 1:900 N HAPPY VALLEY RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-8596
Practice Address - Country:US
Practice Address - Phone:208-206-0261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102903363A00000X
IDPA-1898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY02KYOtherFLORIDA BLUE
FLU4940ZMedicare ID - Type UnspecifiedMEDICARE