Provider Demographics
NPI:1487210977
Name:PITTMAN, JEREL A
Entity Type:Individual
Prefix:
First Name:JEREL
Middle Name:A
Last Name:PITTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7628 N TRYON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-5056
Mailing Address - Country:US
Mailing Address - Phone:980-636-4965
Mailing Address - Fax:
Practice Address - Street 1:7628 N TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5056
Practice Address - Country:US
Practice Address - Phone:980-636-4965
Practice Address - Fax:980-299-2152
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14039424Medicaid