Provider Demographics
NPI:1710367560
Name:DISTASO, ALEXANDRA CATHERINE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ALEXANDRA
Middle Name:CATHERINE
Last Name:DISTASO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:ALEXANDRA
Other - Middle Name:CATHERINE
Other - Last Name:MULLOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:450 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5418
Mailing Address - Country:US
Mailing Address - Phone:617-632-4218
Mailing Address - Fax:617-632-6624
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5418
Practice Address - Country:US
Practice Address - Phone:617-632-4218
Practice Address - Fax:617-632-6624
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2280088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110105490AMedicaid