Healthcare Provider Details

I. General information

NPI: 1174661011
Provider Name (Legal Business Name): LISA LYA PACHECO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA LYA LOGAN DO

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 S RESERVE ST
MISSOULA MT
59801
US

IV. Provider business mailing address

805 S RESERVE ST
MISSOULA MT
59801-2104
US

V. Phone/Fax

Practice location:
  • Phone: 406-549-6600
  • Fax: 406-549-1511
Mailing address:
  • Phone: 406-549-6600
  • Fax: 406-549-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number1440
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number11801
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: