Provider Demographics
NPI:1821042722
Name:SEVERANCE, JERRY W (PA-C)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:SEVERANCE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 W. LACEY BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230
Mailing Address - Country:US
Mailing Address - Phone:559-583-4511
Mailing Address - Fax:559-583-4515
Practice Address - Street 1:1524 W. LACEY BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230
Practice Address - Country:US
Practice Address - Phone:559-583-4511
Practice Address - Fax:559-583-4515
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPA141121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPA141121Medicare PIN