Provider Demographics
NPI:1780746487
Name:BODINE, THERESA (PA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BODINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:571 SAINT JOSEPHS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-873-1244
Practice Address - Street 1:200 NORTH ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1561
Practice Address - Country:US
Practice Address - Phone:315-787-5100
Practice Address - Fax:315-787-5108
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY004448-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1793526Medicaid
NYP0190044448OtherBLUE CROSS
NY105524CKOtherPREFERRED CARE
NYP00003448OtherR.R. MEDICARE
NYP00003448OtherR.R. MEDICARE
NY543855Medicare UPIN