Provider Demographics
NPI:1548025570
Name:IBARRA, OMAR
Entity type:Individual
Prefix:
First Name:OMAR
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 1:8670 FELIZ CREEK DR
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-9361
Mailing Address - Country:US
Mailing Address - Phone:773-946-9991
Mailing Address - Fax:
Practice Address - Street 1:333 LAWS AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-6540
Practice Address - Country:US
Practice Address - Phone:707-468-1010
Practice Address - Fax:707-468-0696
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64594363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical