Provider Demographics
NPI:1548777808
Name:ROAE, DAVID KEITH (FNP)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:KEITH
Last Name:ROAE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 153
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:14813-0153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 153
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NY
Practice Address - Zip Code:14813-0153
Practice Address - Country:US
Practice Address - Phone:585-268-5700
Practice Address - Fax:585-268-9192
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY22-2807681OtherTAX ID