Provider Demographics
NPI:1942273149
Name:SEVERANCE, MICHAEL E (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
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:PO BOX 281721
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5405 S 500 E STE 205
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7420
Practice Address - Country:US
Practice Address - Phone:801-479-0174
Practice Address - Fax:801-479-8888
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4728390-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000096008Medicare PIN
UTP39588Medicare UPIN