Provider Demographics
NPI:1689463317
Name:IBAROLA, CHRISTOPHER STEPHEN GANGAN
Entity type:Individual
Prefix:
First Name:CHRISTOPHER STEPHEN
Middle Name:GANGAN
Last Name:IBAROLA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504816
Mailing Address - Street 2:
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950-4309
Mailing Address - Country:US
Mailing Address - Phone:670-323-6780
Mailing Address - Fax:670-323-8741
Practice Address - Street 1:PO BOX 504816
Practice Address - Street 2:
Practice Address - City:SAIPAN
Practice Address - State:MP
Practice Address - Zip Code:96950-4309
Practice Address - Country:US
Practice Address - Phone:670-323-6780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040180225100000X
MP0065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist