Provider Demographics
NPI:1730316787
Name:BECKMAN, ROLAND RYAN (CCP)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:RYAN
Last Name:BECKMAN
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 S 45TH W
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5542
Mailing Address - Country:US
Mailing Address - Phone:208-521-6337
Mailing Address - Fax:650-615-9995
Practice Address - Street 1:156 S 45TH W
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-5542
Practice Address - Country:US
Practice Address - Phone:208-521-6337
Practice Address - Fax:650-615-9995
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090909242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist