Basic Information
Provider Information | |||||||||
NPI: | 1326037342 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROAN | ||||||||
FirstName: | PETER | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3340 E GOLDSTONE WAY | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836421026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083020200 | ||||||||
FaxNumber: | 2083020255 | ||||||||
Practice Location | |||||||||
Address1: | 4424 E FLAMINGO AVE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | NAMPA | ||||||||
State: | ID | ||||||||
PostalCode: | 836879306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083020200 | ||||||||
FaxNumber: | 2083020255 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/21/2005 | ||||||||
LastUpdateDate: | 11/15/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | M6613 | ID | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | M-6613 | ID | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 003895300 | 05 | ID |   | MEDICAID | 000010149232 | 01 | ID | BLUE SHIELD | OTHER | P00182709 | 01 | ID | RAILROAD MEDICARE | OTHER | B3390 | 01 | ID | BLUE CROSS | OTHER |