Provider Demographics
NPI:1285748954
Name:ROBERTS, KENNETH M (PA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5956
Mailing Address - Country:US
Mailing Address - Phone:386-673-5100
Mailing Address - Fax:386-673-6014
Practice Address - Street 1:300 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5956
Practice Address - Country:US
Practice Address - Phone:386-673-5100
Practice Address - Fax:386-673-6014
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAB551YMedicare PIN