Basic Information
| Provider Information | |||||||||
| NPI: | 1194277665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBARRA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Credential: | AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 WALLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064149100 | ||||||||
| FaxNumber: | 8063545717 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S COULTER ST | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064149100 | ||||||||
| FaxNumber: | 8063545717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2016 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | AP132388 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LG0600X | AP132388 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | AP132388 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200678790 A | 05 | OK | MEDICAID | 366677802 | 05 | TX | MEDICAID | 366677801 | 05 | TX | MEDICAID | 54485525 | 05 | NM | MEDICAID |