Healthcare Provider Details

I. General information

NPI: 1518735166
Provider Name (Legal Business Name): MR. NICHOLAS MATTHEW ROALOFS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44311 MONTEREY AVE
PALM DESERT CA
92260-2710
US

IV. Provider business mailing address

44311 MONTEREY AVE
PALM DESERT CA
92260-2710
US

V. Phone/Fax

Practice location:
  • Phone: 760-773-6616
  • Fax: 760-773-6618
Mailing address:
  • Phone: 760-773-6616
  • Fax: 760-773-6618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68045
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: