Healthcare Provider Details

I. General information

NPI: 1134069388
Provider Name (Legal Business Name): NICHOLAS DISTASIO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 HOLLAND ST
SOMERVILLE MA
02144-2705
US

IV. Provider business mailing address

14 WILDWOOD AVE
ARLINGTON MA
02476-6422
US

V. Phone/Fax

Practice location:
  • Phone: 339-222-2235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN2359368
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: