Provider Demographics
NPI:1962611384
Name:BODEN, KATHRYN EVERHART (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:EVERHART
Last Name:BODEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:EVERHART
Other - Last Name:NEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:966 PEPPERWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311
Mailing Address - Country:US
Mailing Address - Phone:919-817-7811
Mailing Address - Fax:
Practice Address - Street 1:4401 RAMSEY STREET, FAST MED URGENT CARE
Practice Address - Street 2:SUITE 104
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311
Practice Address - Country:US
Practice Address - Phone:910-354-3372
Practice Address - Fax:910-491-5813
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101227OtherLICENSE NUMBER