Provider Demographics
NPI:1770580250
Name:IBANEZ, JOHN J (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:IBANEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 BEN ALI DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-8937
Mailing Address - Country:US
Mailing Address - Phone:859-236-6621
Mailing Address - Fax:859-238-0471
Practice Address - Street 1:1250 BEN ALI DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-8937
Practice Address - Country:US
Practice Address - Phone:859-236-6621
Practice Address - Fax:859-238-0471
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000194007OtherANTHEM FACETS#
KY24356111000OtherPASSPORT MCR ADVANTAGE
KY24356111000OtherPASSPORT MCR ADVANTAGE
KY97002465Medicare PIN
KY000000194007OtherANTHEM FACETS#