Healthcare Provider Details

I. General information

NPI: 1124364070
Provider Name (Legal Business Name): ALICIA LYNNE IBANEZ P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 AYRSLEY TOWN BLVD SUITE 400
CHARLOTTE NC
28273-3595
US

IV. Provider business mailing address

120 CHANDELEUR DR
MOORESVILLE NC
28117-5954
US

V. Phone/Fax

Practice location:
  • Phone: 980-297-7733
  • Fax: 980-297-7744
Mailing address:
  • Phone: 508-335-6122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-03995
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: