Provider Demographics
NPI:1346296795
Name:IBACH, MARIA D (PA)
Entity Type:Individual
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First Name:MARIA
Middle Name:D
Last Name:IBACH
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Gender:F
Credentials:PA
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Mailing Address - Street 1:5400 TRINITY RD
Mailing Address - Street 2:STE 105
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6001
Mailing Address - Country:US
Mailing Address - Phone:919-851-2174
Mailing Address - Fax:919-854-7774
Practice Address - Street 1:10941 RAVEN RIDGE RD
Practice Address - Street 2:STE 105
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-6487
Practice Address - Country:US
Practice Address - Phone:919-235-0543
Practice Address - Fax:919-235-0542
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2013-04-09
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Provider Licenses
StateLicense IDTaxonomies
NC103988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007856100Medicaid
FLGX111ZMedicare PIN
FL007856100Medicaid