Provider Demographics
NPI:1568078392
Name:ROAN, LEISA JOAN (NP)
Entity Type:Individual
Prefix:
First Name:LEISA
Middle Name:JOAN
Last Name:ROAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 VIKING DR STE 101
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2165
Mailing Address - Country:US
Mailing Address - Phone:318-747-8100
Mailing Address - Fax:318-747-8150
Practice Address - Street 1:2539 VIKING DR STE 100
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-1611
Practice Address - Country:US
Practice Address - Phone:318-747-8105
Practice Address - Fax:318-747-8150
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA214754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1023205Medicaid