Basic Information
| Provider Information | |||||||||
| NPI: | 1316100571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BODERO | ||||||||
| FirstName: | JOANAH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 816759 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330810759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549642450 | ||||||||
| FaxNumber: | 9549646084 | ||||||||
| Practice Location | |||||||||
| Address1: | 4302 ALTON RD | ||||||||
| Address2: | SUITE 830 | ||||||||
| City: | MIAMI BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331402891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056742950 | ||||||||
| FaxNumber: | 9549646084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2008 | ||||||||
| LastUpdateDate: | 07/08/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA9104352 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.