Provider Demographics
NPI:1235449810
Name:SEVERA, KELLY A (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:SEVERA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:COSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:401 ROUTE 73 N STE 320
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3426
Mailing Address - Country:US
Mailing Address - Phone:856-872-7055
Mailing Address - Fax:
Practice Address - Street 1:151 GREENTREE RD STE B
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-9416
Practice Address - Country:US
Practice Address - Phone:856-702-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00246200363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ006129Medicare PIN