Provider Demographics
NPI:1982473963
Name:IBANEZ, MARC LOUIE MAGUNDAYAO
Entity type:Individual
Prefix:
First Name:MARC LOUIE
Middle Name:MAGUNDAYAO
Last Name:IBANEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:21 BAYBERRY LN
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-4001
Mailing Address - Country:US
Mailing Address - Phone:929-238-4710
Mailing Address - Fax:
Practice Address - Street 1:21 BAYBERRY LN
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-4001
Practice Address - Country:US
Practice Address - Phone:929-238-4710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-01
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012828225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant