Provider Demographics
NPI:1316975469
Name:DISTASIO, SUSAN A (APRN)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:A
Last Name:DISTASIO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE MEDICAL CENTER DRIVE
Mailing Address - Street 2:DARTMOUTH HITCHCOCK - PAIN MEDICINE/ANESTHESIOLOGY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:603-650-6039
Mailing Address - Fax:
Practice Address - Street 1:ONE MEDICAL CENTER DRIVE
Practice Address - Street 2:DARTMOUTH HITCHCOCK - PAIN MEDICINE/ANESTHESIOLOGY
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-6039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH064077-23363L00000X
CT001896364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4196368Medicaid
S67612Medicare UPIN
CT4196368Medicaid
CT4196368Medicaid