Provider Demographics
NPI:1801819040
Name:BODNER, JASON KRISTOPHER (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:KRISTOPHER
Last Name:BODNER
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-245-2100
Mailing Address - Fax:336-768-7782
Practice Address - Street 1:140 KIMEL PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6160
Practice Address - Country:US
Practice Address - Phone:336-245-2100
Practice Address - Fax:336-768-7782
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8103258Medicaid
NC8103258Medicaid