Provider Demographics
NPI:1417724246
Name:BOEDICKER, GRIFFIN HUNTER
Entity type:Individual
Prefix:
First Name:GRIFFIN
Middle Name:HUNTER
Last Name:BOEDICKER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 WELLS AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-3301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 WELLS AVE STE 500
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-3301
Practice Address - Country:US
Practice Address - Phone:617-965-4263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MAPA101506363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program