Basic Information
| Provider Information | |||||||||
| NPI: | 1932600970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIVINGSTON | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | GLEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 506 CONTINENTAL ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562585548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056610689 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 S BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562581934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5075329661 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2018 | ||||||||
| LastUpdateDate: | 07/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R035316 | SD | N | Nursing Service Providers | Registered Nurse | 367500000X | 2208 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.