Provider Demographics
NPI:1740312735
Name:PACHECO, SEAN NICHOLAS (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:SEAN
Middle Name:NICHOLAS
Last Name:PACHECO
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02364-1101
Mailing Address - Country:US
Mailing Address - Phone:781-585-5454
Mailing Address - Fax:
Practice Address - Street 1:1269 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5245
Practice Address - Country:US
Practice Address - Phone:617-734-7766
Practice Address - Fax:617-734-3663
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPAAP2317Medicare ID - Type UnspecifiedMEDICARE PART B NUMBER