Healthcare Provider Details

I. General information

NPI: 1932855285
Provider Name (Legal Business Name): PHILLIP BODNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

1616 N CENTRAL AVE APT 1123
PHOENIX AZ
85004-1654
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-5011
  • Fax:
Mailing address:
  • Phone: 954-681-3998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number243999
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: