Basic Information
| Provider Information | |||||||||
| NPI: | 1346296795 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBACH | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 TRINITY RD | ||||||||
| Address2: | STE 105 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276076001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198512174 | ||||||||
| FaxNumber: | 9198547774 | ||||||||
| Practice Location | |||||||||
| Address1: | 10941 RAVEN RIDGE RD | ||||||||
| Address2: | STE 105 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276146487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192350543 | ||||||||
| FaxNumber: | 9192350542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 04/09/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 103988 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 007856100 | 05 | FL | MEDICAID |