Healthcare Provider Details

I. General information

NPI: 1023987831
Provider Name (Legal Business Name): MIRANDA LYNN DE ROOS-LOUDEN PA-C, MPA, BIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRANDA DE ROOS-LOUDEN PA-C, MPA, BIS

II. Dates (important events)

Enumeration Date: 10/30/2025
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8613 ROUTE 29 STE 101
FAIRFAX VA
22031-2171
US

IV. Provider business mailing address

825 FAIRFAX AVE
NORFOLK VA
23507-1914
US

V. Phone/Fax

Practice location:
  • Phone: 571-350-8400
  • Fax: 703-208-3108
Mailing address:
  • Phone: 619-865-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011001252
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: