Healthcare Provider Details

I. General information

NPI: 1194580795
Provider Name (Legal Business Name): MICHAEL DISTASIO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

YALE NEW HAVEN HEALTH 789 HOWARD AVENUE
NEW HAVEN CT
06460
US

IV. Provider business mailing address

69 CARRIAGE PATH S
MILFORD CT
06460-7544
US

V. Phone/Fax

Practice location:
  • Phone: 203-430-6379
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number154019
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14094
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: