Individual
ALICIA LYNNE IBANEZ
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.
Contact information
Practice address
2131 AYRSLEY TOWN BLVD, SUITE 400, CHARLOTTE, NC 28273-3595
(980) 297-7733
(980) 297-7744
Mailing address
120 CHANDELEUR DR, MOORESVILLE, NC 28117-5954
(508) 335-6122
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
0010-03995
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1124364070
—
NC
05
—
1570PA
—
SC
05
—
8103056
—
NC
Enumeration date
12/21/2012
Last updated
07/20/2015
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