Provider Demographics
NPI:1114481496
Name:BOEDIGHEIMER, VICKY
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:
Last Name:BOEDIGHEIMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICKY
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2002 MEDICAL PKWY STE 630
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3059
Mailing Address - Country:US
Mailing Address - Phone:410-224-2260
Mailing Address - Fax:410-224-3090
Practice Address - Street 1:2002 MEDICAL PKWY STE 630
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3059
Practice Address - Country:US
Practice Address - Phone:410-224-2260
Practice Address - Fax:410-224-3090
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007708363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty