Healthcare Provider Details

I. General information

NPI: 1760841696
Provider Name (Legal Business Name): BRADY ESPLIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2016
Last Update Date: 02/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 ADAMS ST
AFTON WY
83110-9621
US

IV. Provider business mailing address

901 ADAMS ST
AFTON WY
83110-9621
US

V. Phone/Fax

Practice location:
  • Phone: 307-887-6473
  • Fax:
Mailing address:
  • Phone: 307-887-6473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPT668
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: