Provider Demographics
NPI:1356355291
Name:PITTMAN, ROGER D (PAC)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:PITTMAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:133 FOURTH STREET
Mailing Address - City:GONZALES
Mailing Address - State:CA
Mailing Address - Zip Code:93926-0646
Mailing Address - Country:US
Mailing Address - Phone:831-675-3601
Mailing Address - Fax:831-675-3966
Practice Address - Street 1:133 FOURTH STREET
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:CA
Practice Address - Zip Code:93926-0646
Practice Address - Country:US
Practice Address - Phone:831-675-3601
Practice Address - Fax:831-675-3966
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS90356Medicare UPIN
CA0PA180360Medicare PIN