Healthcare Provider Details

I. General information

NPI: 1043177116
Provider Name (Legal Business Name): MADISON YBARRA-GUSTAV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADISON YBARRA

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 SONORA CIR
REDLANDS CA
92373-8508
US

IV. Provider business mailing address

432 SONORA CIR
REDLANDS CA
92373-8508
US

V. Phone/Fax

Practice location:
  • Phone: 909-255-5745
  • Fax:
Mailing address:
  • Phone: 909-255-5745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: