Provider Demographics
NPI:1972972735
Name:FUSCO, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:FUSCO
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 1:520 JEFFERSON AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:AVON BY THE SEA
Mailing Address - State:NJ
Mailing Address - Zip Code:07717-1165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 JEFFERSON AVE APT 5
Practice Address - Street 2:
Practice Address - City:AVON BY THE SEA
Practice Address - State:NJ
Practice Address - Zip Code:07717-1165
Practice Address - Country:US
Practice Address - Phone:973-714-1467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002066002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer