Healthcare Provider Details

I. General information

NPI: 1700264314
Provider Name (Legal Business Name): STEPHANIE L SEVERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 32ND AVE S
FARGO ND
58103-6132
US

IV. Provider business mailing address

400 E 3RD ST
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0969
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0779
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: