MEDICARE: LAURA IBANEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-16317	NC

General Provider Information

NPI Number	:	1245029636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA IBANEZ

Provider Business Mailing Address
First Line	:	10730 SURREY GREEN LN APT 303
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-8960
Country	:	US
Telephone Number	:	704-910-9306
Fax Number	:

Provider Business Practice Location Address
First Line	:	4105 MATTHEWS MINT HILL RD
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-3633
Country	:	US
Telephone Number	:	704-910-9306
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2025
Last Update Date	:	03/10/2026

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Directions to “ LAURA IBANEZ ” Practice Location

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