Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 9859A | WY |
Y | 208600000X | Surgeon | 9859A | WY |
NPI | 1013079524 |
---|---|
Provider Name | Jonah Jess Green |
First Address | Afton, WY 83110-9409 |
Second Address | Afton, WY 83110-9409 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2006 |
Last Update Date | 14/07/2016 |