Provider Demographics
NPI:1093767808
Name:BODNER, BRADLEY T (PA-C)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:BODNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 WESTHILL DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54402-3770
Mailing Address - Country:US
Mailing Address - Phone:715-843-1000
Mailing Address - Fax:
Practice Address - Street 1:2800 WESTHILL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-3771
Practice Address - Country:US
Practice Address - Phone:715-843-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1312-023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41923000Medicaid
WIS84998Medicare UPIN