=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255813911
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID MCNEELY ROBERTS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2018
-----------------------------------------------------
Last Update Date | 06/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 FRIST BLVD STE 4
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-595-5302
-----------------------------------------------------
Fax | 772-595-5304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12070 OLD LINE CTR STE 303
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20602-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-595-5302
-----------------------------------------------------
Fax | 772-595-5304
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------