Provider Demographics
NPI:1699170258
Name:ROAN, VICTORIA (OD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:
Last Name:ROAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:2606 116TH AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-1422
Practice Address - Country:US
Practice Address - Phone:425-462-7664
Practice Address - Fax:425-462-6429
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD 60474759152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2050775Medicaid