Provider Demographics
NPI:1235939232
Name:ROAN, TONI MAJEL (RT(R)(CT))
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:MAJEL
Last Name:ROAN
Suffix:
Gender:
Credentials:RT(R)(CT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 E GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6045
Mailing Address - Country:US
Mailing Address - Phone:505-979-4406
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRRT072002085R0202X
NMCT004902471C3401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology