Provider Demographics
NPI:1700157948
Name:ROMAN, ERIC G (NP)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:G
Last Name:ROMAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 HIGHWAY 150 S
Mailing Address - Street 2:P.O. BOX 177
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5340
Mailing Address - Country:US
Mailing Address - Phone:307-789-3464
Mailing Address - Fax:307-789-7373
Practice Address - Street 1:831 HIGHWAY 150 S
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5340
Practice Address - Country:US
Practice Address - Phone:307-789-3464
Practice Address - Fax:307-789-7373
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY25318.1148364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY25318.1148OtherLICENSE