Provider Demographics
NPI:1245029636
Name:IBANEZ, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:IBANEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10730 SURREY GREEN LN APT 303
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-8960
Mailing Address - Country:US
Mailing Address - Phone:704-910-9306
Mailing Address - Fax:
Practice Address - Street 1:10730 SURREY GREEN LN APT 303
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-8960
Practice Address - Country:US
Practice Address - Phone:704-910-9306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical