Healthcare Provider Details

I. General information

NPI: 1245029636
Provider Name (Legal Business Name): LAURA IBANEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 MATTHEWS MINT HILL RD
MATTHEWS NC
28105-3633
US

IV. Provider business mailing address

10730 SURREY GREEN LN APT 303
MATTHEWS NC
28105-8960
US

V. Phone/Fax

Practice location:
  • Phone: 704-910-9306
  • Fax:
Mailing address:
  • Phone: 704-910-9306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-16317
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: