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: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 N LA CHOLLA BLVD
TUCSON AZ
85741-3529
US

IV. Provider business mailing address

660 NW 155TH TER
PEMBROKE PINES FL
33028-1505
US

V. Phone/Fax

Practice location:
  • Phone: 520-742-9000
  • 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: