Healthcare Provider Details

I. General information

NPI: 1326037342
Provider Name (Legal Business Name): PETER G ROAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 1ST ST S
NAMPA ID
83651-3703
US

IV. Provider business mailing address

3310 E RIVERNEST LN
BOISE ID
83706-6928
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-7869
  • Fax: 208-466-5359
Mailing address:
  • Phone: 208-869-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberM-6613
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberM6613
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberM-6613
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: