Provider Demographics
NPI:1457987133
Name:PETUSEVSKY, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PETUSEVSKY
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 1:905 KENILWORTH AVE APT 497
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3527
Mailing Address - Country:US
Mailing Address - Phone:954-591-5873
Mailing Address - Fax:
Practice Address - Street 1:1100 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5814
Practice Address - Country:US
Practice Address - Phone:704-355-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-13
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program