Healthcare Provider Details

I. General information

NPI: 1174276133
Provider Name (Legal Business Name): ERNESTO IBARRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 01/31/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

IV. Provider business mailing address

15385 KATY FWY # 305
HOUSTON TX
77094-1801
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone: 210-730-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number009363
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: