Healthcare Provider Details

I. General information

NPI: 1871958272
Provider Name (Legal Business Name): STEVEN ROBERT IBANEZ CPNP-PC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 05/06/2021
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 CALLE DE ALEGRA STE B
LAS CRUCES NM
88005-3423
US

IV. Provider business mailing address

385 CALLE DE ALEGRA STE A
LAS CRUCES NM
88005-3423
US

V. Phone/Fax

Practice location:
  • Phone: 575-674-2880
  • Fax: 575-674-2881
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP129845
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: