Provider Demographics
NPI:1326037342
Name:ROAN, PETER G (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:ROAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-0200
Mailing Address - Fax:208-302-0255
Practice Address - Street 1:4424 E FLAMINGO AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9306
Practice Address - Country:US
Practice Address - Phone:208-302-0200
Practice Address - Fax:208-302-0255
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6613207RI0011X
IDM-6613207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003895300Medicaid
ID000010149232OtherBLUE SHIELD
IDP00182709OtherRAILROAD MEDICARE
IDB3390OtherBLUE CROSS
ID1130855Medicare ID - Type Unspecified
IDB3390OtherBLUE CROSS
ID003895300Medicaid