Provider Demographics
NPI:1538787932
Name:IBARRA OLIVA, ANDY
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:IBARRA OLIVA
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 1:22863 NEPTUNE RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-5744
Mailing Address - Country:US
Mailing Address - Phone:561-379-9849
Mailing Address - Fax:
Practice Address - Street 1:301 NORTHPOINT PKWY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-7904
Practice Address - Country:US
Practice Address - Phone:561-712-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-12
Last Update Date:2020-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28021225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant