Provider Demographics
NPI:1376209742
Name:GAUTAM, ROSY
Entity Type:Individual
Prefix:MRS
First Name:ROSY
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6760 JOSEPH EDGAR CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-2667
Mailing Address - Country:US
Mailing Address - Phone:703-217-4382
Mailing Address - Fax:
Practice Address - Street 1:2901 TELESTAR CT STE 200
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1262
Practice Address - Country:US
Practice Address - Phone:703-573-3494
Practice Address - Fax:703-573-5353
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180585207R00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024180585OtherLICENSE