Basic Information
| Provider Information | |||||||||
| NPI: | 1841464120 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PETTUS | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE MEDICAL CENTER DR | ||||||||
| Address2: | DARTMOUTH-HITCHCOCK MEDICAL CENTER, DEPT. OF PATHOLOGY | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036505000 | ||||||||
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| Practice Location | |||||||||
| Address1: | ONE MEDICAL CENTER DR | ||||||||
| Address2: | DARTMOUTH-HITCHCOCK MEDICAL CENTER, DEPT. OF PATHOLOGY | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036505000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207ZP0102X | 250580 | MA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 16131 | NH | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 1021925 | 05 | VT | MEDICAID | 3086997 | 05 | NH | MEDICAID |