Healthcare Provider Details

I. General information

NPI: 1942273149
Provider Name (Legal Business Name): MICHAEL E SEVERANCE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 S 500 E STE 205
OGDEN UT
84405-7420
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-0174
  • Fax: 801-479-0312
Mailing address:
  • Phone: 801-475-3500
  • Fax: 801-475-3494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4728390-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: