MEDICARE: MR. KEITH WESLEY ROBERTS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	25MP00362300	NJ
2	363A00000X	Physician Assistant	001006432	NC

General Provider Information

NPI Number	:	1811385776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEITH WESLEY ROBERTS PA-C

Provider Business Mailing Address
First Line	:	5050 EDWARDS MILL RD
Second Line	:	APARTMENT D
City	:	RALEIGH
State	:	NC
Zip	:	27612-4439
Country	:	US
Telephone Number	:	540-915-3487
Fax Number	:

Provider Business Practice Location Address
First Line	:	2800 BLUE RIDGE RD
Second Line	:	SUITE 400
City	:	RALEIGH
State	:	NC
Zip	:	27607-6478
Country	:	US
Telephone Number	:	919-787-5380
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2014
Last Update Date	:	03/26/2021

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