MEDICARE: TESSA CAMILLE PITTMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	T66419058	OTHER	VA	ATHLETIC TRAINING

General Provider Information

NPI Number	:	1578029807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TESSA CAMILLE PITTMAN

Provider Business Mailing Address
First Line	:	1250 MCLIN HOLLOW RD
Second Line	:
City	:	ROSE HILL
State	:	VA
Zip	:	24281-8275
Country	:	US
Telephone Number	:	865-585-8595
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 MCLIN HOLLOW RD
Second Line	:
City	:	ROSE HILL
State	:	VA
Zip	:	24281-8275
Country	:	US
Telephone Number	:	865-585-8595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2019
Last Update Date	:	02/12/2019

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Directions to “ TESSA CAMILLE PITTMAN ” Practice Location

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