Provider Demographics
NPI:1265277255
Name:ROAN, JAMES MICHAEL JR (LMT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:ROAN
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 25TH ST APT 304
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-5100
Mailing Address - Country:US
Mailing Address - Phone:360-502-1545
Mailing Address - Fax:
Practice Address - Street 1:4322 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2233
Practice Address - Country:US
Practice Address - Phone:425-258-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60211419225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist