Healthcare Provider Details

I. General information

NPI: 1962263798
Provider Name (Legal Business Name): MATTHEW LEWIS PITTS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR STE 8600
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

600 GRESHAM DR STE 8600
NORFOLK VA
23507-1904
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-6005
  • Fax:
Mailing address:
  • Phone: 757-388-6005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010165
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: