Provider Demographics
NPI:1518735166
Name:ROALOFS, NICHOLAS MATTHEW
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:MATTHEW
Last Name:ROALOFS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14044 W CAMELBACK RD STE 118
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-9481
Mailing Address - Country:US
Mailing Address - Phone:623-547-2600
Mailing Address - Fax:
Practice Address - Street 1:14044 W CAMELBACK RD STE 118
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9481
Practice Address - Country:US
Practice Address - Phone:623-547-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-13
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11051363A00000X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant