Provider Demographics
NPI:1912488156
Name:BODDEN, NICOLAS RODRIGUEZ
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:RODRIGUEZ
Last Name:BODDEN
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 1:1913 E M FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-5828
Mailing Address - Country:US
Mailing Address - Phone:956-204-4968
Mailing Address - Fax:
Practice Address - Street 1:1913 E M FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-5828
Practice Address - Country:US
Practice Address - Phone:956-204-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-26
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer