Provider Demographics
NPI:1811200124
Name:IBONIA, KATRINA TAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:TAN
Last Name:IBONIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1249 N WOODLAND ST APT 104
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4791
Mailing Address - Country:US
Mailing Address - Phone:559-736-4082
Mailing Address - Fax:
Practice Address - Street 1:9300 VALLEY CHILDRENS PL # SE21
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8762
Practice Address - Country:US
Practice Address - Phone:559-353-8769
Practice Address - Fax:559-353-5580
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY459032080N0001X
GUM-20292080N0001X
390200000X
CAA1656642080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program