Healthcare Provider Details

I. General information

NPI: 1932600970
Provider Name (Legal Business Name): NICHOLAS GLEN LIVINGSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S BRUCE ST
MARSHALL MN
56258-1934
US

IV. Provider business mailing address

506 CONTINENTAL ST
MARSHALL MN
56258-5548
US

V. Phone/Fax

Practice location:
  • Phone: 507-532-9661
  • Fax:
Mailing address:
  • Phone: 605-661-0689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR035316
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2208
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: