Provider Demographics
NPI:1548334774
Name:ROAN, JOAN (PT)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:ROAN
Suffix:
Gender:F
Credentials:PT
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 331
Mailing Address - Street 2:137 WEST MAIN STREET
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-0331
Mailing Address - Country:US
Mailing Address - Phone:336-246-3554
Mailing Address - Fax:336-246-4547
Practice Address - Street 1:137 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-0331
Practice Address - Country:US
Practice Address - Phone:336-246-3554
Practice Address - Fax:336-246-4547
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1067225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4282130OtherQUAL CHOICE
NC07811OtherBCBS
NC7200032Medicaid
NC7200032Medicaid