Healthcare Provider Details

I. General information

NPI: 1619865995
Provider Name (Legal Business Name): ROMAN AGUON SALAS RN, NP, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE
ELMENDORF AFB AK
99506-3702
US

IV. Provider business mailing address

11327 FORTINO PT
SAN DIEGO CA
92131-4229
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-2778
  • Fax:
Mailing address:
  • Phone: 619-753-9015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number5210
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SC0200X
TaxonomyCritical Care Medicine Clinical Nurse Specialist
License Number5210
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95035330
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number5210
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number5210
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95035330
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: