Healthcare Provider Details

I. General information

NPI: 1730384942
Provider Name (Legal Business Name): BODHI M ANDERSON PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EMBARCADERO CTR STE 1900
SAN FRANCISCO CA
94111-3723
US

IV. Provider business mailing address

1 EMBARCADERO CTR STE 1900
SAN FRANCISCO CA
94111-3723
US

V. Phone/Fax

Practice location:
  • Phone: 415-578-3100
  • Fax: 415-252-7176
Mailing address:
  • Phone: 415-658-6791
  • Fax: 415-520-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06494
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number52038
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5824
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17980
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number52038
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberAMD-416
License Number StateHI
# 7
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA5215
License Number StateMA
# 8
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5824
License Number StateAZ
# 9
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number018111
License Number StateNY
# 10
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.005337
License Number StateIL
# 11
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA031084
License Number StateDC
# 12
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA5215
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: