Provider Demographics
NPI:1174913545
Name:ROMAN, EDWIN ROLANDO
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:ROLANDO
Last Name:ROMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13454 NE SANDY BLVD
Mailing Address - Street 2:APT. Y3
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-2681
Mailing Address - Country:US
Mailing Address - Phone:321-693-8201
Mailing Address - Fax:
Practice Address - Street 1:13454 NE SANDY BLVD
Practice Address - Street 2:APT. Y3
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2681
Practice Address - Country:US
Practice Address - Phone:321-693-8201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19797225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist