Basic Information
| Provider Information | |||||||||
| NPI: | 1447213012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOEDE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253300633 | ||||||||
| FaxNumber: | 4253389637 | ||||||||
| Practice Location | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253379556 | ||||||||
| FaxNumber: | 4253579186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 01/24/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0309BO | 01 | WA | REGENCE | OTHER | 1838BO | 01 | WA | REGENCE | OTHER | 911745305-98223-C004 | 01 | WA | TRICARE | OTHER | 0213610 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 8350183 | 05 | WA | MEDICAID | 0273078 | 01 | WA | DEPT L/I | OTHER | 8350183 | 01 | WA | DSHS | OTHER | 8750BO | 01 | WA | REGENCE BLUE SHIELD | OTHER | P00414140 | 01 | WA | RAILROAD MEDICARE | OTHER | 0251421 | 01 | WA | L&I | OTHER | 1830BO | 01 | WA | REGENCE BLUE SHIELD | OTHER | 7787375 | 01 | WA | AETNA | OTHER | 8940177 | 01 | WA | L & I CRIME VICTIMS | OTHER | 3568BO | 01 | WA | REGENCE BLUE SHIELD | OTHER |