Healthcare Provider Details

I. General information

NPI: 1568375574
Provider Name (Legal Business Name): JOHN ROAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 ALLEN ST
JAMESTOWN NY
14701-6968
US

IV. Provider business mailing address

21 NEW YORK AVE APT 6
LAKEWOOD NY
14750-1231
US

V. Phone/Fax

Practice location:
  • Phone: 716-338-0022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: