Provider Demographics
NPI:1609862275
Name:BOEDIGHEIMER, MARIA THERESE (PA C)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:THERESE
Last Name:BOEDIGHEIMER
Suffix:
Gender:F
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 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:3120 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7131
Practice Address - Country:US
Practice Address - Phone:928-771-3704
Practice Address - Fax:928-771-0434
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85000971363A00000X
AZ4435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4435OtherAZ LICENSE
AZ927112Medicaid
AZZ169027Medicare PIN
ILK23278Medicare PIN
AZ4435OtherAZ LICENSE