Provider Demographics
NPI:1932600970
Name:LIVINGSTON, NICHOLAS GLEN
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GLEN
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 CONTINENTAL ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-5548
Mailing Address - Country:US
Mailing Address - Phone:605-661-0689
Mailing Address - Fax:
Practice Address - Street 1:300 S BRUCE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1934
Practice Address - Country:US
Practice Address - Phone:507-532-9661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR035316163W00000X
MN2208367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse