Provider Demographics
NPI:1902443518
Name:IBARRA, SERGIO MIGUEL (ATC, EMT)
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:MIGUEL
Last Name:IBARRA
Suffix:
Gender:M
Credentials:ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:6766 KELLY ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-6553
Mailing Address - Country:US
Mailing Address - Phone:805-245-0211
Mailing Address - Fax:
Practice Address - Street 1:5500 CAMPANILE DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92182-4313
Practice Address - Country:US
Practice Address - Phone:619-594-7652
Practice Address - Fax:619-594-7654
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0017492255A2300X
NJ25MT002034002255A2300X
CA0906021342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA090602134OtherNATIONAL ATHLETIC TRAINER'S ASSOCIATION