Provider Demographics
NPI:1861762627
Name:PITTMAN, COREY LEE
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:LEE
Last Name:PITTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:COREY
Other - Middle Name:LEE
Other - Last Name:PITTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1225 N 159TH DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-2753
Mailing Address - Country:US
Mailing Address - Phone:602-672-2853
Mailing Address - Fax:623-932-2096
Practice Address - Street 1:1225 N 159TH DR
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-2753
Practice Address - Country:US
Practice Address - Phone:602-672-2853
Practice Address - Fax:623-932-2096
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20568756172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver