Provider Demographics
NPI:1518793983
Name:PACLEB, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:PACLEB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4875 COLE ST UNIT 50
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-1864
Mailing Address - Country:US
Mailing Address - Phone:678-763-2684
Mailing Address - Fax:
Practice Address - Street 1:4875 COLE ST UNIT 50
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-1864
Practice Address - Country:US
Practice Address - Phone:678-763-2684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032083363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner