Provider Demographics
NPI:1508346289
Name:IMAN, ROSHAWNA (PNP-BC)
Entity Type:Individual
Prefix:
First Name:ROSHAWNA
Middle Name:
Last Name:IMAN
Suffix:
Gender:F
Credentials:PNP-BC
Other - Prefix:
Other - First Name:ROSHAWNA
Other - Middle Name:
Other - Last Name:MONGOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1247 SUNCREST TOWN CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1876
Mailing Address - Country:US
Mailing Address - Phone:304-599-8000
Mailing Address - Fax:304-599-8003
Practice Address - Street 1:9000 COOMBS FARM RD STE 102
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1150
Practice Address - Country:US
Practice Address - Phone:304-599-8003
Practice Address - Fax:304-599-8003
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV80117363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics