Provider Demographics
NPI:1114345287
Name:BODHI, ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BODHI
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 1:100 RUNNING DEER DR
Mailing Address - Street 2:
Mailing Address - City:DECATURVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38329-5285
Mailing Address - Country:US
Mailing Address - Phone:865-216-6327
Mailing Address - Fax:
Practice Address - Street 1:100 RUNNING DEER DR
Practice Address - Street 2:
Practice Address - City:DECATURVILLE
Practice Address - State:TN
Practice Address - Zip Code:38329-5285
Practice Address - Country:US
Practice Address - Phone:865-216-6327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant