Provider Demographics
NPI:1013052240
Name:BODEKOR, ERIN LIZABETH (NP)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:LIZABETH
Last Name:BODEKOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:LIZABETH
Other - Last Name:MCGRUDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 655-B
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-8655
Mailing Address - Country:US
Mailing Address - Phone:585-341-3015
Mailing Address - Fax:585-784-8815
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX 655-B
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-341-3015
Practice Address - Fax:585-784-8815
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304562363LA2200X
NYF3045621363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03054395Medicaid
NY03054395Medicaid