Provider Demographics
NPI:1235128349
Name:BODEN, CARLENE KAY (PA)
Entity Type:Individual
Prefix:
First Name:CARLENE
Middle Name:KAY
Last Name:BODEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-442-1900
Mailing Address - Fax:
Practice Address - Street 1:1152 E 200 N
Practice Address - Street 2:AMERICAN FORK HOSPITAL - RADIATION ONCOLOGY
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2004
Practice Address - Country:US
Practice Address - Phone:801-535-8163
Practice Address - Fax:801-355-4011
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKBEVB12103K00000X
AK103852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MB1206383OtherDEA
UT000064434Medicare PIN