Healthcare Provider Details

I. General information

NPI: 1073306809
Provider Name (Legal Business Name): JOSHUA IBANEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2025
Last Update Date: 05/24/2025
Certification Date: 05/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8761
US

IV. Provider business mailing address

717 W ATHERTON DR APT 325
MANTECA CA
95337-9534
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-3000
  • Fax:
Mailing address:
  • Phone: 951-691-7452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: