Provider Demographics
NPI:1730384942
Name:ANDERSON, BODHI M (PAC)
Entity type:Individual
Prefix:
First Name:BODHI
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EMBARCADERO CTR STE 1900
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-3723
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:415-520-0904
Practice Address - Street 1:1 EMBARCADERO CTR STE 1900
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94111-3723
Practice Address - Country:US
Practice Address - Phone:415-578-3100
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06494363A00000X
CA52038363A00000X, 363AM0700X
AZ5824363A00000X, 363AM0700X
TXPA17980363A00000X
HIAMD-416363AM0700X
MAPA5215363AM0700X, 363A00000X
NY018111363AM0700X
IL085.005337363AM0700X
DCPA031084363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA116345EDCMedicare PIN
PA5072986OtherBLUE CROSS/KEYSTONE CENTRAL