Provider Demographics
NPI:1740841113
Name:IBARRA, AYRTON T
Entity type:Individual
Prefix:
First Name:AYRTON
Middle Name:T
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 1:223 K ST SE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-5742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17615 SE 272ND ST STE 104
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4957
Practice Address - Country:US
Practice Address - Phone:206-612-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60817446225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist