Provider Demographics
NPI:1518521145
Name:IBARRA, GABRIEL MARTIN (PA)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:MARTIN
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 1:112 SOUTHLAKE CIR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-5368
Mailing Address - Country:US
Mailing Address - Phone:601-859-8550
Mailing Address - Fax:
Practice Address - Street 1:112 SOUTHLAKE CIR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-5368
Practice Address - Country:US
Practice Address - Phone:601-859-8550
Practice Address - Fax:601-859-8556
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical