Basic Information
| Provider Information | |||||||||
| NPI: | 1356731715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBASCO | ||||||||
| FirstName: | DOROTHY DAWN | ||||||||
| MiddleName: | BALDOVINO | ||||||||
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| Credential: | A.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 616788 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328616788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074477120 | ||||||||
| FaxNumber: | 4077700661 | ||||||||
| Practice Location | |||||||||
| Address1: | 6320 OLD WINTER GARDEN RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328351381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072900555 | ||||||||
| FaxNumber: | 4072950028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 363LF0000X | ARNP 9352814 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 014492800 | 05 | FL | MEDICAID |