NPIMap

Individual provider Active NPI

David Alden Boedeker, PA-C

  • Medical Physician Assistant
  • Lansing, MI
National Provider Identifier
1508311085
Registry record updated Oct 4, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
License
PT696 Issued in WY
Practice address
2815 S. Pennsylvania Ave
Suite 204
Lansing, MI 48910-3496
Phone
(517) 267-0200
Fax
(517) 267-1877
NPI assigned
Aug 24, 2016
Last updated
Oct 4, 2021By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 4, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X 5601008520 MI
Medical Physician Assistant 363AM0700X PT696 WY Primary

Addresses

Primary practice location

2815 S. Pennsylvania Ave
Suite 204
Lansing, MI 48910-3496

Mailing address

2815 S. Pennsylvania Ave
Suite 204
Lansing, MI 48910-3496
Phone (517) 267-0200

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WY, MI, SD3 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
I20160929000599 WY Practitioner - Physician Assistant 1557658960 Reassigns benefits to 2 organizations
I20190626001130 MI Practitioner - Physician Assistant 1557658960 Reassigns benefits to 2 organizations
I20250421002627 SD Practitioner - Physician Assistant 1557658960 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2016
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

2201 S Douglas Hwy
Suite 120
Gillette, WY 82718-5408
Phone (800) 446-9556

7220 Mount Rushmore Rd
Rapid City, SD 57702-8754
Phone (605) 737-9151

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
5601008520MIMDMedical Physician Assistant
PT696WYMDMedical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Edward W. Sparrow Hospital Association CurrentSince Jun 1, 2019 Accepting new patients
Black Hills Orthopedic & Spine Center of Wyoming PC CurrentSince Jul 16, 2025 Accepting new patients
Campbell County Hospital District CurrentSince Aug 29, 2016 Accepting new patients
Campbell County Hospital District CurrentSince Aug 29, 2016 Accepting new patients

Locations

8175 Reliable Pkwy
Chicago, IL 60686

1215 E Michigan Ave
Lansing, MI 48912
Phone (517) 336-8080

716 N Clippert St
Lansing, MI 48912
Phone (517) 253-4000

800 E Columbia St
Mason, MI 48854
Phone (517) 244-8900

7220 Mount Rushmore Rd
Rapid City, SD 57702
Phone (605) 737-9144

2201 S Douglas Hwy
Ste 120
Gillette, WY 82718
Phone (307) 370-1574

501 S Burma Ave
Gillette, WY 82716
Phone (307) 682-8811

501 S Burma Ave
Fl 3
Gillette, WY 82716
Phone (307) 688-3636

508 Stocktrail Ave
Ste A
Gillette, WY 82716
Phone (307) 686-1413

Interoperability endpoints

  • Direct secure messaging: dboedeker@ccmgclinics.gwaydirect.com

Organizations & group practices 9

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 20

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 20

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1471996800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1633305600000",
    "number": "1508311085",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2815 S. PENNSYLVANIA AVE",
            "address_2": "SUITE 204",
            "city": "LANSING",
            "state": "MI",
            "postal_code": "489103496",
            "telephone_number": "517-267-0200",
            "fax_number": "517-267-1877"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2815 S. PENNSYLVANIA AVE",
            "address_2": "SUITE 204",
            "city": "LANSING",
            "state": "MI",
            "postal_code": "489103496",
            "telephone_number": "517-267-0200",
            "fax_number": "517-267-1877"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOEDEKER",
        "first_name": "DAVID",
        "middle_name": "ALDEN",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-08-24",
        "last_updated": "2021-10-04",
        "certification_date": "2021-10-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "MI",
            "license": "5601008520",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "WY",
            "license": "PT696",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lansing, MI

Sources for this page

Verify at the official NPI Registry.