Healthcare Provider Details

I. General information

NPI: 1457373276
Provider Name (Legal Business Name): JAMES BRIAN BODE APRN-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 W EDGERTON AVE
GREENFIELD WI
53220-4420
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 414-325-5244
  • Fax:
Mailing address:
  • Phone: 414-389-2377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number970-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: