Provider Demographics
NPI:1972683498
Name:SEVERSON, DEAN DENNIS (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DEAN
Middle Name:DENNIS
Last Name:SEVERSON
Suffix:
Gender:M
Credentials:CRNA
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 210
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-0210
Mailing Address - Country:US
Mailing Address - Phone:081-825-4700
Mailing Address - Fax:801-825-9076
Practice Address - Street 1:2055 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9819
Practice Address - Country:US
Practice Address - Phone:435-843-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6280859-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1972683498Medicaid