Provider Demographics
NPI:1689795320
Name:ROBERTS, DANIELLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 MERCEDES WAY
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-8368
Mailing Address - Country:US
Mailing Address - Phone:631-254-7380
Mailing Address - Fax:
Practice Address - Street 1:51 MERCEDES WAY
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-8368
Practice Address - Country:US
Practice Address - Phone:631-254-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011644363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical