Provider Demographics
NPI:1356957039
Name:BODILY, TANNER BLAYLOCK
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:BLAYLOCK
Last Name:BODILY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 TROY AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2906
Mailing Address - Country:US
Mailing Address - Phone:208-680-7929
Mailing Address - Fax:
Practice Address - Street 1:3360 WASHINGTON PKWY STE 1
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8333
Practice Address - Country:US
Practice Address - Phone:208-524-3416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ID363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program