Provider Demographics
NPI:1194325266
Name:IBARRA, JESUS ROLANDO (PA-C)
Entity type:Individual
Prefix:MR
First Name:JESUS
Middle Name:ROLANDO
Last Name:IBARRA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19600 SERENITY LN
Mailing Address - Street 2:
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645-2189
Mailing Address - Country:US
Mailing Address - Phone:850-291-9591
Mailing Address - Fax:
Practice Address - Street 1:911 W 38TH ST STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1107
Practice Address - Country:US
Practice Address - Phone:512-451-7935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant