WYBOM – On-line Physician Assistant License Application – New Individual Record
Personal Information
Please provide the following Personal Identifying Information to create your new record with the Wyoming Board of Medicine.
Title
Mr.
Mrs.
Ms.
First Name
*
Middle Name
Last Name
*
Generational Suffix
Professional Suffix
DO
MD
PA
PA-C
*
Birth City
*
Birth State or Province
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
EC
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
LM
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UN
US
UT
VA
VI
VT
WA
WI
WN
WV
WY
YT
*
Birth Country
*
Date of Birth
*
Social Security Number
*
Gender
Female
Male
*
Ethnicity
American
Asian Other
C/S American
Cuban
Engl/Scot/Welch/Sc-Irish
French
German
Hispanic
Indian (Am/Can/Mex/Esk/AK)
Irish
Italian
Mexican
N African
N C S Amer or Can Other
Not Hispanic
Polish
Puerto Rican
S European/ex Spain Other
SC Asian
Spanish Other & Unknown
SW Asian/Pacific Islander
Swedish/Danish/Norwegian
Unknown
W European Other
Click "Submit" to save your entries and be forwarded to the next page in the process.
Clicking "Cancel" will discard your entries and return you to the Wyoming Board of Medicine home page.