Provider Demographics
NPI:1366641425
Name:IBARRA, MAXIMO (PA)
Entity Type:Individual
Prefix:
First Name:MAXIMO
Middle Name:
Last Name:IBARRA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 1277
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90609-1277
Mailing Address - Country:US
Mailing Address - Phone:562-906-6470
Mailing Address - Fax:562-946-9465
Practice Address - Street 1:15725 E WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90603-2347
Practice Address - Country:US
Practice Address - Phone:562-947-7754
Practice Address - Fax:562-902-9599
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10811363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE47950Medicare UPIN