Provider Demographics
NPI:1750599452
Name:BODENHAMER, DEIRDRE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DEIRDRE
Middle Name:
Last Name:BODENHAMER
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 1:10495 WHITE ROCK RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-5530
Mailing Address - Country:US
Mailing Address - Phone:916-364-0724
Mailing Address - Fax:
Practice Address - Street 1:10495 WHITE ROCK RD
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-5530
Practice Address - Country:US
Practice Address - Phone:916-364-0724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 15402363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant