Healthcare Provider Details

I. General information

NPI: 1295324838
Provider Name (Legal Business Name): SHANNON PACHECO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON STARUK PA-C

II. Dates (important events)

Enumeration Date: 01/17/2021
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8530 LA MESA BLVD STE 200
LA MESA CA
91942-0966
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2585
  • Fax:
Mailing address:
  • Phone: 619-515-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65562
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA8729
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: