Healthcare Provider Details

I. General information

NPI: 1558824698
Provider Name (Legal Business Name): JESSICA LEIGH PACUCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2019
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 RAPHINE RD
RAPHINE VA
24472-2541
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-851-1760
  • Fax:
Mailing address:
  • Phone: 540-224-5715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110006609
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: