Provider Demographics
NPI:1336481589
Name:PACHECO, MARIA LISSETTE (DPM)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LISSETTE
Last Name:PACHECO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1039 EXECUTIVE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-7900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1039 EXECUTIVE DR STE 102
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-7900
Practice Address - Country:US
Practice Address - Phone:423-541-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2021-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN789213E00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ066173Medicaid