Provider Demographics
NPI:1083860548
Name:BODMER, ANDREW DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DAVID
Last Name:BODMER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18040 SW LOWER BOONES FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7259
Practice Address - Country:US
Practice Address - Phone:503-216-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZT-4239363AM0700X
ORPA161375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500655799Medicaid
ORR170316Medicare PIN
ORR170314Medicare PIN
ORR168851Medicare PIN
OR500655799Medicaid
ORR170313Medicare PIN
ORR170315Medicare PIN