Provider Demographics
NPI:1174701965
Name:LIVINGSTON, STEPHANIE STINE (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:STINE
Last Name:LIVINGSTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:C
Other - Last Name:STINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1540 S TAMIAMI TRL
Practice Address - Street 2:SUITE303
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2930
Practice Address - Country:US
Practice Address - Phone:941-917-8791
Practice Address - Fax:917-917-8793
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104497363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33181OtherBCBS FL
FL293076500Medicaid
FLAJ392XMedicare PIN
FL293076500Medicaid
FLAJ392WMedicare PIN
FLAJ392QMedicare PIN
FL33181OtherBCBS FL
FLAJ392ZMedicare PIN