Provider Demographics
NPI:1215130562
Name:ROULEAU, KEITH DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:DAVID
Last Name:ROULEAU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29605 SOLANA WAY
Mailing Address - Street 2:#N6
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-3758
Mailing Address - Country:US
Mailing Address - Phone:510-691-1267
Mailing Address - Fax:
Practice Address - Street 1:29605 SOLANA WAY
Practice Address - Street 2:#N6
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-3758
Practice Address - Country:US
Practice Address - Phone:510-691-1267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9193363A00000X
CAPA19013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MR3132569OtherDEA NUMBER
CA0PA190130Medicare PIN