Healthcare Provider Details

I. General information

NPI: 1174701965
Provider Name (Legal Business Name): STEPHANIE STINE LIVINGSTON P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE C. STINE P.A.

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 S TAMIAMI TRL SUITE303
SARASOTA FL
34239-2930
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-8791
  • Fax: 917-917-8793
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9104497
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: