Provider Demographics
NPI:1407510522
Name:SIMKO, MICHAEL DYLAN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DYLAN
Last Name:SIMKO
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 1:8312 GREELEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-2904
Mailing Address - Country:US
Mailing Address - Phone:571-512-1478
Mailing Address - Fax:
Practice Address - Street 1:8312 GREELEY BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-2904
Practice Address - Country:US
Practice Address - Phone:571-512-1478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604516225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty