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General NPI Number Information
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NPI Number | 1033700059
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Entity Type | Organization
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Legal Business Name | BOARDMAN SURGICAL LLC
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Dates
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Enumeration Date | 02/02/2021
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Last Update Date | 02/03/2021
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Provider Practice Location Address
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Address Line | 15074 SE BEVINGTON AVE
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City | MILWAUKIE
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State | OR
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Zip | 97267-3357
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Country | US
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Telephone | 503-307-0159
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Fax |
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Provider Business Mailing Address
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Address Line | 15074 SE BEVINGTON AVE
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City | MILWAUKIE
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State | OR
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Zip | 97267-3357
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Country | US
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Telephone | 503-307-0159
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ELLIE BOARDMAN
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Credential | CSFA
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Telephone | 503-307-0159
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State |
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