Provider Demographics
NPI:1184732927
Name:BODIE, GARY WILFRED (CRNA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:WILFRED
Last Name:BODIE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13595 STATE HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13911 RIDGEDALE DR
Practice Address - Street 2:SUITE 350
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1771
Practice Address - Country:US
Practice Address - Phone:952-932-9012
Practice Address - Fax:952-932-7122
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0677190367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered