Individual
MARY LOUISE BODEWES
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PAC
Contact information
Practice address
630 W MAPLE ST, FARMINGTON, NM 87401-6113
(505) 609-6349
Mailing address
PO BOX 844088, DALLAS, TX 75284-4088
(505) 609-2258
(505) 609-2259
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
988
WI
363A00000X
Physician Assistant
PA.005343
CO
363A00000X
Physician Assistant
Primary
PA2021-0130
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42971200
—
WI
Enumeration date
09/14/2006
Last updated
11/08/2024
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