Healthcare Provider Details

I. General information

NPI: 1497360689
Provider Name (Legal Business Name): RAMESH GAUTAM DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1373
US

IV. Provider business mailing address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1373
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7500
  • Fax:
Mailing address:
  • Phone: 757-314-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1091132
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: