Basic Information
Provider Information | |||||||||
NPI: | 1992033062 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PACHECO | ||||||||
FirstName: | ANNE | ||||||||
MiddleName: | BORDELON | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | HEARING AID SPECIALI | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MERKL | ||||||||
OtherFirstName: | ANNE | ||||||||
OtherMiddleName: | BORDELON | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6700 WASHINGTON AVE S | ||||||||
Address2: |   | ||||||||
City: | EDEN PRAIRIE | ||||||||
State: | MN | ||||||||
PostalCode: | 553443405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6123511529 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 350 NW EASTMAN PKWY | ||||||||
Address2: |   | ||||||||
City: | GRESHAM | ||||||||
State: | OR | ||||||||
PostalCode: | 970307203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036673832 | ||||||||
FaxNumber: | 5034654768 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2009 | ||||||||
LastUpdateDate: | 12/10/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X |   | OR | N |   | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   | 237700000X | HAS-P-10129545 | OR | Y |   | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |   |
ID Information
ID | Type | State | Issuer | Description | HAS-P-10129545 | 01 | OR | OREGON HEALTH LICENSE | OTHER |