Provider Demographics
NPI:1508311085
Name:BOEDEKER, DAVID ALDEN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALDEN
Last Name:BOEDEKER
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Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:2815 S. PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-3496
Mailing Address - Country:US
Mailing Address - Phone:517-267-0200
Mailing Address - Fax:517-267-1877
Practice Address - Street 1:2815 S. PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3496
Practice Address - Country:US
Practice Address - Phone:517-267-0200
Practice Address - Fax:517-267-1877
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601008520363AM0700X
WYPT696363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical