Provider Demographics
NPI:1457776882
Name:IBARRA, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:IBARRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:984 SAINT CATHERINE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79907-3357
Mailing Address - Country:US
Mailing Address - Phone:915-240-0568
Mailing Address - Fax:
Practice Address - Street 1:8915 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1212
Practice Address - Country:US
Practice Address - Phone:915-225-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX778951363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily