Healthcare Provider Details

I. General information

NPI: 1346354461
Provider Name (Legal Business Name): AUDREY LISTON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

787 MARKET ST STE 9
HANCOCK MI
49930
US

IV. Provider business mailing address

325 E H ST
IRON MOUNTAIN MI
49801-4760
US

V. Phone/Fax

Practice location:
  • Phone: 906-482-7762
  • Fax:
Mailing address:
  • Phone: 906-774-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101012074
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: