Healthcare Provider Details

I. General information

NPI: 1013379304
Provider Name (Legal Business Name): BERTRAND BODO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8214 MILWAUKEE AVE STE 200
LUBBOCK TX
79424-0923
US

IV. Provider business mailing address

8214 MILWAUKEE AVE STE 200
LUBBOCK TX
79424-0923
US

V. Phone/Fax

Practice location:
  • Phone: 806-475-5544
  • Fax: 806-475-5545
Mailing address:
  • Phone: 806-475-5544
  • Fax: 806-475-5545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP130666
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: