| NPI | 1568649234 |
|---|---|
| Former Name | BETHANY JANE STORK |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10001172A) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.003092) |
| 363AS0400X Physician Assistant, Surgical (Licence: IN 10001172A) | |
| Enumeration Date | 2008-01-24 |
| Last Update Date | 2019-01-30 |