Provider Demographics
NPI:1740803238
Name:BODEN, TAYLOR (MMS, RD, PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:BODEN
Suffix:
Gender:F
Credentials:MMS, RD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 E ERIE ST STE 2020
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2994
Mailing Address - Country:US
Mailing Address - Phone:312-695-6647
Mailing Address - Fax:312-695-0044
Practice Address - Street 1:259 E ERIE ST STE 2020
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2994
Practice Address - Country:US
Practice Address - Phone:312-695-6647
Practice Address - Fax:312-695-0044
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300041213Medicaid