Provider Demographics
NPI:1891017448
Name:BODILY, CHRISTOPHER H (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:H
Last Name:BODILY
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 1:5004 KING RICHARDS ROW
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-1577
Mailing Address - Country:US
Mailing Address - Phone:360-791-7626
Mailing Address - Fax:
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PKWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5846
Practice Address - Country:US
Practice Address - Phone:360-791-7626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical