Provider Demographics
NPI:1093258584
Name:DISTASIO, MARY ANGELS (MPA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANGELS
Last Name:DISTASIO
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8895 FONTAINEBLEAU BLVD APT 105
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4423
Mailing Address - Country:US
Mailing Address - Phone:305-992-0171
Mailing Address - Fax:786-209-2076
Practice Address - Street 1:150 E 1ST AVE STE 105
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4925
Practice Address - Country:US
Practice Address - Phone:305-825-0300
Practice Address - Fax:786-209-2076
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator