Provider Demographics
NPI:1124364070
Name:IBANEZ, ALICIA LYNNE (PA)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:LYNNE
Last Name:IBANEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CHANDELEUR DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5954
Mailing Address - Country:US
Mailing Address - Phone:508-335-6122
Mailing Address - Fax:
Practice Address - Street 1:2131 AYRSLEY TOWN BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3595
Practice Address - Country:US
Practice Address - Phone:980-297-7733
Practice Address - Fax:980-297-7744
Is Sole Proprietor?:No
Enumeration Date:2012-12-21
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03995363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1570PAMedicaid
NC1124364070Medicaid
NC8103056Medicaid
NC8103056Medicaid