Healthcare Provider Details

I. General information

NPI: 1659854677
Provider Name (Legal Business Name): JAY BOARDMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13755 N LITCHFIELD RD STE 105
SURPRISE AZ
85379-4288
US

IV. Provider business mailing address

14109 N 83RD AVE APT 329
PEORIA AZ
85381-4779
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-5900
  • Fax:
Mailing address:
  • Phone: 469-693-2144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7273
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: