Provider Demographics
NPI:1730531260
Name:IBARDOLAZA, MARIA ISABEL (AGNP-C)
Entity type:Individual
Prefix:
First Name:MARIA ISABEL
Middle Name:
Last Name:IBARDOLAZA
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16391 WATERWAY CIR APT A
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-3248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:282 E SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-6323
Practice Address - Country:US
Practice Address - Phone:310-830-9962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2016-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003734363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology