Healthcare Provider Details

I. General information

NPI: 1770580250
Provider Name (Legal Business Name): JOHN J IBANEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 VETERANS DR
LEXINGTON KY
40502-2235
US

IV. Provider business mailing address

419 COLDSTREAM DR
DANVILLE KY
40422-1013
US

V. Phone/Fax

Practice location:
  • Phone: 859-233-4511
  • Fax:
Mailing address:
  • Phone: 859-236-6621
  • Fax: 859-238-0471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA405
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: