Healthcare Provider Details

I. General information

NPI: 1063453363
Provider Name (Legal Business Name): BOARDMAN HEALTH AND WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4713 PINE ST SW
S BOARDMAN MI
49680-9761
US

IV. Provider business mailing address

4713 PINE ST SW
S BOARDMAN MI
49680-9761
US

V. Phone/Fax

Practice location:
  • Phone: 231-369-2656
  • Fax:
Mailing address:
  • Phone: 231-369-2656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301069428
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003799
License Number StateMI

VIII. Authorized Official

Name: THOMAS KEANE STETLER
Title or Position: OFFICER
Credential: PA-C
Phone: 231-369-2656