Provider Demographics
NPI:1811516776
Name:INDRIES BOGDE, PRISCILLA A (PA-C)
Entity type:Individual
Prefix:MS
First Name:PRISCILLA
Middle Name:A
Last Name:INDRIES BOGDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8585 E HARTFORD DR STE 103
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-5472
Mailing Address - Country:US
Mailing Address - Phone:480-562-6600
Mailing Address - Fax:480-562-6606
Practice Address - Street 1:8585 E HARTFORD DR STE 103
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-5472
Practice Address - Country:US
Practice Address - Phone:480-562-6600
Practice Address - Fax:480-562-6606
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ8611363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty