Healthcare Provider Details

I. General information

NPI: 1316975469
Provider Name (Legal Business Name): SUSAN A DISTASIO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE MEDICAL CENTER DRIVE DARTMOUTH HITCHCOCK - PAIN MEDICINE/ANESTHESIOLOGY
LEBANON NH
03756-0001
US

IV. Provider business mailing address

ONE MEDICAL CENTER DRIVE DARTMOUTH HITCHCOCK - PAIN MEDICINE/ANESTHESIOLOGY
LEBANON NH
03756-0001
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-6039
  • Fax:
Mailing address:
  • Phone: 603-650-6039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number064077-23
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code364SX0200X
TaxonomyOncology Clinical Nurse Specialist
License Number001896
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: