Provider Demographics
NPI:1548236334
Name:PASTERNACKI, JACQUE P (PAC)
Entity type:Individual
Prefix:
First Name:JACQUE
Middle Name:P
Last Name:PASTERNACKI
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 JEFFERSON ST NE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4379
Mailing Address - Country:US
Mailing Address - Phone:505-242-1711
Mailing Address - Fax:505-242-0291
Practice Address - Street 1:8080 ACADEMY RD NE STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1110
Practice Address - Country:US
Practice Address - Phone:505-244-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-PA009363A00000X
NM81PA009364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000T9885Medicaid
NMT9885Medicaid
NM000T9885Medicaid
NMT9885Medicaid