Provider Demographics
NPI:1154358588
Name:SEVERANCE, ANDREW B (CRNA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:B
Last Name:SEVERANCE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9701 VENTNOR AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MARGATE CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08402-2222
Mailing Address - Country:US
Mailing Address - Phone:609-822-4242
Mailing Address - Fax:609-822-3211
Practice Address - Street 1:9701 VENTNOR AVE STE 201
Practice Address - Street 2:
Practice Address - City:MARGATE CITY
Practice Address - State:NJ
Practice Address - Zip Code:08402-2222
Practice Address - Country:US
Practice Address - Phone:609-822-4242
Practice Address - Fax:609-822-3211
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00281100367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ222041639OtherTAX ID