Healthcare Provider Details

I. General information

NPI: 1790597433
Provider Name (Legal Business Name): JUAN CARLOS IBARRA MADRIGAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 W POPLAR AVE
PORTERVILLE CA
93257-5839
US

IV. Provider business mailing address

267 N LOTAS ST
PORTERVILLE CA
93257-2916
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 559-920-3850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number66239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: