Provider Demographics
NPI:1205814167
Name:BOISEN, VICTORIA (DO)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BOISEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5708 E LAKE SAMMAMISH PKWY SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-8942
Mailing Address - Country:US
Mailing Address - Phone:425-688-5277
Mailing Address - Fax:425-233-6268
Practice Address - Street 1:5708 E LAKE SAMMAMISH PKWY SE
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-8942
Practice Address - Country:US
Practice Address - Phone:425-688-5277
Practice Address - Fax:425-233-6268
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOPO60935786207Q00000X
ORDO166249207Q00000X
CA20A11678207Q00000X
WAOP60935786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273739600Medicaid
FL273739600Medicaid
FLP00332533Medicare PIN