Healthcare Provider Details

I. General information

NPI: 1841283843
Provider Name (Legal Business Name): STEPHEN L LISTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 SMITH AVE N STE 602
SAINT PAUL MN
55102-2387
US

IV. Provider business mailing address

2211 PARK AVE
MINNEAPOLIS MN
55404-3711
US

V. Phone/Fax

Practice location:
  • Phone: 651-227-0821
  • Fax: 651-297-6597
Mailing address:
  • Phone: 612-871-1144
  • Fax: 612-871-2012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number23911
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: