Individual
LUIS E VIDAL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
9300 DEWITT LOOP, FORT BELVOIR, VA 22060-5285
(571) 231-0374
Mailing address
9300 DEWITT LOOP, FORT BELVOIR, VA 22060-5285
(571) 231-0374
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0110008968
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0110008968
VIRGINIA STATE BOARD OF MEDICINE PHYSICIAN ASSISTANT LICENSE
VA
Enumeration date
09/12/2007
Last updated
08/10/2023
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