Healthcare Provider Details

I. General information

NPI: 1992512214
Provider Name (Legal Business Name): ALIDA MILLER LIVINGSTON PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 BRIARGATE PKWY STE 300
COLORADO SPRINGS CO
80920-7837
US

IV. Provider business mailing address

PO BOX 129
TELLURIDE CO
81435-0129
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-7669
  • Fax:
Mailing address:
  • Phone: 205-259-9228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number0008607
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: