Provider Demographics
NPI:1114040425
Name:BODKIN, RONNIE TARSHIS (NP)
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:TARSHIS
Last Name:BODKIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 WINDSOR ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 WOODRIDGE RD
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-3724
Practice Address - Country:US
Practice Address - Phone:508-358-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA117434363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP1540Medicare ID - Type Unspecified