Provider Demographics
NPI:1326037342
Name:ROAN, PETER G (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:ROAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 E RIVERNEST LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6928
Mailing Address - Country:US
Mailing Address - Phone:208-869-7700
Mailing Address - Fax:
Practice Address - Street 1:207 1ST ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3703
Practice Address - Country:US
Practice Address - Phone:208-466-7869
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6613207RI0011X
IDM-6613207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00182709OtherRAILROAD MEDICARE
ID003895300Medicaid
ID000010149232OtherBLUE SHIELD
IDB3390OtherBLUE CROSS
ID1130855Medicare ID - Type Unspecified
IDB3390OtherBLUE CROSS
ID003895300Medicaid