Healthcare Provider Details

I. General information

NPI: 1114728391
Provider Name (Legal Business Name): ROBERT JOSEPH IBARRA FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2025
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1148 W BASELINE RD
MESA AZ
85210-5971
US

IV. Provider business mailing address

3719 E INVERNESS AVE UNIT 6
MESA AZ
85206-3802
US

V. Phone/Fax

Practice location:
  • Phone: 480-559-3149
  • Fax:
Mailing address:
  • Phone: 406-860-8861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number283519
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: