Healthcare Provider Details

I. General information

NPI: 1548236334
Provider Name (Legal Business Name): JACQUE P PASTERNACKI PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 ACADEMY RD NE STE B
ALBUQUERQUE NM
87111-1110
US

IV. Provider business mailing address

6801 JEFFERSON ST NE SUITE 350
ALBUQUERQUE NM
87109-4379
US

V. Phone/Fax

Practice location:
  • Phone: 505-244-0080
  • Fax:
Mailing address:
  • Phone: 505-242-1711
  • Fax: 505-242-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number81-PA009
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: