Provider Demographics
NPI:1801047956
Name:SEVVOM, AMANDA JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:SEVVOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JEAN
Other - Last Name:PRIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15747 W 74TH PL
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80007-7965
Mailing Address - Country:US
Mailing Address - Phone:303-921-2038
Mailing Address - Fax:303-420-8831
Practice Address - Street 1:3555 LUTHERAN PKWY STE 340
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6039
Practice Address - Country:US
Practice Address - Phone:303-996-6005
Practice Address - Fax:303-420-8831
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1801047956Medicaid