Provider Demographics
NPI:1780643429
Name:BOHAN, TAMELA J
Entity Type:Individual
Prefix:
First Name:TAMELA
Middle Name:J
Last Name:BOHAN
Suffix:
Gender:F
Credentials:
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 697
Mailing Address - Street 2:
Mailing Address - City:FORT YATES
Mailing Address - State:ND
Mailing Address - Zip Code:58538-0697
Mailing Address - Country:US
Mailing Address - Phone:701-854-3678
Mailing Address - Fax:701-854-7181
Practice Address - Street 1:001 NORTH AGENCY AVENUE
Practice Address - Street 2:
Practice Address - City:FT. YATES
Practice Address - State:ND
Practice Address - Zip Code:58538
Practice Address - Country:US
Practice Address - Phone:701-854-3678
Practice Address - Fax:701-854-7181
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist