Provider Demographics
NPI:1932898657
Name:KIBARA, SAMUEL (APRN)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:KIBARA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 E PHILLIPS BLVD UNIT 3
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-7553
Mailing Address - Country:US
Mailing Address - Phone:972-207-1080
Mailing Address - Fax:
Practice Address - Street 1:961 E PHILLIPS BLVD UNIT 3
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-7553
Practice Address - Country:US
Practice Address - Phone:972-207-1080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2024-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95396611163W00000X
TX1117621363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health