Healthcare Provider Details

I. General information

NPI: 1285150946
Provider Name (Legal Business Name): NICHOLAS DESORBO APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 EASTERN BLVD
GLASTONBURY CT
06033-1207
US

IV. Provider business mailing address

63 EASTERN BLVD
GLASTONBURY CT
06033-1207
US

V. Phone/Fax

Practice location:
  • Phone: 860-368-0862
  • Fax:
Mailing address:
  • Phone: 318-955-2963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number12.007374
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12.007374
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: