Provider Demographics
NPI:1053969477
Name:PACHECO, MANUEL BRANDON IV (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:BRANDON
Last Name:PACHECO
Suffix:IV
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:PO BOX 5122
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-5122
Mailing Address - Country:US
Mailing Address - Phone:505-280-5336
Mailing Address - Fax:
Practice Address - Street 1:6400 PASEO DEL NORTE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1718
Practice Address - Country:US
Practice Address - Phone:505-596-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2019-0076363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant