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Medical >> Physician Assistant >> Physician Assistants & Advanced Practice Nursing Providers

Registrant NPI Number: 1154716595

Individual Registrant:
Gender: M
Not Sole Proprietor

Location and contact information for practice:
4092 FOXWOOD DR 101 VA BEACH, VA 23462-5225 US
Tel: 757-686-3508  Fax: 757-686-0541

Contact information for business:
PO BOX 7549  PORTSMOUTH, VA 23707-0549 US
Tel: 757-686-3525  Fax: 757-686-0541

Registration Information:
NPI: 1154716595
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y363AM0700XPhysician Assistants & Advanced Practice Nursing Providers
Physician Assistant

Legacy codes, insurance codes and state license numbers:



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