Healthcare Provider Details

I. General information

NPI: 1689893604
Provider Name (Legal Business Name): AMANDA LIVINGSTON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 EASTSIDE HWY
STEVENSVILLE MT
59870-2224
US

IV. Provider business mailing address

PO BOX 16900
MISSOULA MT
59808-6900
US

V. Phone/Fax

Practice location:
  • Phone: 406-777-2775
  • Fax: 406-777-2796
Mailing address:
  • Phone: 406-327-4620
  • Fax: 406-549-5928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number318
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: