Provider Demographics
NPI:1114957289
Name:IBARRA, MARTHA ASUNCION
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ASUNCION
Last Name:IBARRA
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 1:4290 POLK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1524
Mailing Address - Country:US
Mailing Address - Phone:619-563-0507
Mailing Address - Fax:619-563-0015
Practice Address - Street 1:4290 POLK AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1524
Practice Address - Country:US
Practice Address - Phone:619-563-0507
Practice Address - Fax:619-563-0015
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP12112363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner