Healthcare Provider Details

I. General information

NPI: 1902538663
Provider Name (Legal Business Name): CONNOR ROAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

IV. Provider business mailing address

39 CHIMNEY STONE WAY
SHREVEPORT LA
71115-3154
US

V. Phone/Fax

Practice location:
  • Phone: 318-221-8411
  • Fax:
Mailing address:
  • Phone: 318-401-7756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number327785
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: