=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346296795
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA D IBACH PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 04/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10941 RAVEN RIDGE RD STE 105
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27614-6487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-235-0543
-----------------------------------------------------
Fax | 919-235-0542
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5400 TRINITY RD STE 105
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27607-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-851-2174
-----------------------------------------------------
Fax | 919-854-7774
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 103988
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------