Healthcare Provider Details

I. General information

NPI: 1629806872
Provider Name (Legal Business Name): ROSELLER BALAGTAS SIMBULAN JR NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ROS SIMBULAN NP

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 08/15/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16245 CATENARY DR
WOODBRIDGE VA
22191-6035
US

IV. Provider business mailing address

16245 CATENARY DR
WOODBRIDGE VA
22191-6035
US

V. Phone/Fax

Practice location:
  • Phone: 571-214-9320
  • Fax:
Mailing address:
  • Phone: 571-214-9320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN500006216
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024198218
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001301746
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: