Provider Demographics
NPI:1083642862
Name:SEVERY, ELIZABETH A (PA)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:A
Last Name:SEVERY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:BETH
Other - Middle Name:A
Other - Last Name:SEVERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:31537 RANCHO PUEBLO RD
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-4841
Mailing Address - Country:US
Mailing Address - Phone:951-303-2277
Mailing Address - Fax:
Practice Address - Street 1:31537 RANCHO PUEBLO RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-4841
Practice Address - Country:US
Practice Address - Phone:951-303-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18273363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 18273OtherMEDICAL LICENSE