Provider Demographics
NPI:1174625537
Name:LIVINGSTON, CHARLES MARK (PA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MARK
Last Name:LIVINGSTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:42 SOUTH STATE STREET
Mailing Address - Street 2:BOX 418
Mailing Address - City:NUNDA
Mailing Address - State:NY
Mailing Address - Zip Code:14517
Mailing Address - Country:US
Mailing Address - Phone:585-468-2867
Mailing Address - Fax:
Practice Address - Street 1:61 MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454-1255
Practice Address - Country:US
Practice Address - Phone:585-243-7620
Practice Address - Fax:585-243-1132
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23-004586363A00000X
NY23004586363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP33289Medicare UPIN