Provider Demographics
NPI:1093012734
Name:BOEDECKER, BEAU (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BEAU
Middle Name:
Last Name:BOEDECKER
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 1:6250 THORNRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2651
Mailing Address - Country:US
Mailing Address - Phone:414-303-8332
Mailing Address - Fax:
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 550
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3696
Practice Address - Country:US
Practice Address - Phone:414-385-7150
Practice Address - Fax:414-385-7159
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2701-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant