Basic Information
| Provider Information | |||||||||
| NPI: | 1972683498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEVERSON | ||||||||
| FirstName: | DEAN | ||||||||
| MiddleName: | DENNIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 210 | ||||||||
| Address2: | |||||||||
| City: | ROY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840670210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0818254700 | ||||||||
| FaxNumber: | 8018259076 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840749819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358433600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 6280859-4406 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1972683498 | 05 | WI | MEDICAID |