Provider Demographics
NPI:1538655071
Name:BODNARUK, SASHA ALEXANDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:SASHA
Middle Name:ALEXANDRA
Last Name:BODNARUK
Suffix:
Gender:F
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 1:75 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-1809
Mailing Address - Country:US
Mailing Address - Phone:781-854-2126
Mailing Address - Fax:
Practice Address - Street 1:75 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1809
Practice Address - Country:US
Practice Address - Phone:781-854-2126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant