Basic Information
| Provider Information | |||||||||
| NPI: | 1316975469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DISTASIO | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE MEDICAL CENTER DRIVE | ||||||||
| Address2: | DARTMOUTH HITCHCOCK - PAIN MEDICINE/ANESTHESIOLOGY | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037560001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036506039 | ||||||||
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| Practice Location | |||||||||
| Address1: | ONE MEDICAL CENTER DRIVE | ||||||||
| Address2: | DARTMOUTH HITCHCOCK - PAIN MEDICINE/ANESTHESIOLOGY | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037560001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036506039 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 05/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 064077-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364SX0200X | 001896 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4196368 | 05 | CT | MEDICAID |