Provider Demographics
NPI:1821555780
Name:PITTILLO, AMANDA LAUREN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LAUREN
Last Name:PITTILLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9515 DEERECO RD STE 208
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-2153
Mailing Address - Country:US
Mailing Address - Phone:410-449-2060
Mailing Address - Fax:
Practice Address - Street 1:9515 DEERECO RD STE 208
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2153
Practice Address - Country:US
Practice Address - Phone:410-449-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC07081207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC07081OtherPA LICENSE NUMBER