Basic Information
| Provider Information | |||||||||
| NPI: | 1891269494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 ESSJAY RD STE 170 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166301219 | ||||||||
| FaxNumber: | 7168171726 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 N BUFFALO ST | ||||||||
| Address2: | |||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141271842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166301000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2019 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.