Healthcare Provider Details

I. General information

NPI: 1093201667
Provider Name (Legal Business Name): MATTHEW JACOB DACOSTA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2018
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 AMERICAN LEGION HWY
WESTPORT MA
02790-4128
US

IV. Provider business mailing address

111 FRANKLIN ST APT 2
BRISTOL RI
02809-2327
US

V. Phone/Fax

Practice location:
  • Phone: 508-636-5101
  • Fax: 508-636-3651
Mailing address:
  • Phone: 508-264-1979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA7684
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01269
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: