Provider Demographics
NPI:1407067507
Name:LIVENGOOD, LAWRENCE W (PA)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:W
Last Name:LIVENGOOD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746550
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6550
Mailing Address - Country:US
Mailing Address - Phone:888-236-2263
Mailing Address - Fax:434-654-5574
Practice Address - Street 1:595 MARTHA JEFFERSON DR STE 180
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4669
Practice Address - Country:US
Practice Address - Phone:434-654-5575
Practice Address - Fax:434-654-5574
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1499363A00000X, 363AM0700X
TN1449363AS0400X
VA0110004200363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3665175Medicare PIN