Provider Demographics
NPI:1255463196
Name:BODEN, ROBERT LOUIS (CSA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LOUIS
Last Name:BODEN
Suffix:
Gender:M
Credentials:CSA
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 5327
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:KY
Mailing Address - Zip Code:40362-5327
Mailing Address - Country:US
Mailing Address - Phone:859-514-6675
Mailing Address - Fax:859-514-5962
Practice Address - Street 1:320 SKYVIEW DR
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:KY
Practice Address - Zip Code:40361-1039
Practice Address - Country:US
Practice Address - Phone:859-514-6675
Practice Address - Fax:859-514-5962
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA044363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY755OtherNSAA
KYSA044OtherKY BOARD OF MEDICAL LISCE