Provider Demographics
NPI:1427464585
Name:EGGLESTON, ALICE BUDIMAN (PA-C)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:BUDIMAN
Last Name:EGGLESTON
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 1:1701 14TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-4308
Mailing Address - Country:US
Mailing Address - Phone:202-745-6113
Mailing Address - Fax:202-745-6152
Practice Address - Street 1:1701 14TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-4308
Practice Address - Country:US
Practice Address - Phone:202-745-6113
Practice Address - Fax:202-745-6152
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant