Healthcare Provider Details

I. General information

NPI: 1720135643
Provider Name (Legal Business Name): CHARLES ROY BOARDMAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4226 NE GRAND AVE
PORTLAND OR
97211-3411
US

IV. Provider business mailing address

4226 NE GRAND AVE
PORTLAND OR
97211-3411
US

V. Phone/Fax

Practice location:
  • Phone: 503-333-3977
  • Fax:
Mailing address:
  • Phone: 503-333-3977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number562439
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: