Provider Demographics
NPI:1285763391
Name:LIVELY, JONATHAN (PA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LIVELY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GRESHAM DR STE 8630B
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-388-6115
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR STE 8630B
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002350363A00000X
DCPA030452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC$$$$$$$$$Medicaid