Provider Demographics
NPI:1972262491
Name:PITTMAN, EMMA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:EMMA
Middle Name:ELIZABETH
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:ELIZABETH
Other - Last Name:VENABLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1080 GA HIGHWAY 178
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:GA
Mailing Address - Zip Code:30436-4050
Mailing Address - Country:US
Mailing Address - Phone:912-245-1790
Mailing Address - Fax:
Practice Address - Street 1:1 MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8759
Practice Address - Country:US
Practice Address - Phone:912-535-5555
Practice Address - Fax:912-535-5894
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant