Provider Demographics
NPI:1871825497
Name:TIBONG, STANLEY TITANG (DNP)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:TITANG
Last Name:TIBONG
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 WOODLAND TRACE CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TWP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-9172
Mailing Address - Country:US
Mailing Address - Phone:513-382-4927
Mailing Address - Fax:
Practice Address - Street 1:30 E APPLE ST STE 5254A
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-06
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN. 344514163W00000X
OHAPRN.CNP.15133363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094838Medicaid
OHH225880Medicare PIN