Healthcare Provider Details

I. General information

NPI: 1780746487
Provider Name (Legal Business Name): THERESA BODINE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2006
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NORTH ST
GENEVA NY
14456-1561
US

IV. Provider business mailing address

571 SAINT JOSEPHS BLVD FL 2
ELMIRA NY
14901-3230
US

V. Phone/Fax

Practice location:
  • Phone: 315-787-5100
  • Fax: 315-787-5108
Mailing address:
  • Phone: 607-271-2050
  • Fax: 607-873-1244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004448-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: