Provider Demographics
NPI:1114617560
Name:IRIZARRY, BIANCA MIKAELA
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:MIKAELA
Last Name:IRIZARRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3931 S CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80110-4609
Mailing Address - Country:US
Mailing Address - Phone:386-292-6861
Mailing Address - Fax:
Practice Address - Street 1:3931 S CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80110-4609
Practice Address - Country:US
Practice Address - Phone:386-292-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116886363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant