Provider Demographics
NPI:1063453363
Name:BOARDMAN HEALTH AND WELLNESS, PLLC
Entity Type:Organization
Organization Name:BOARDMAN HEALTH AND WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:KEANE
Authorized Official - Last Name:STETLER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:231-369-2656
Mailing Address - Street 1:4713 PINE ST SW
Mailing Address - Street 2:
Mailing Address - City:S BOARDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49680-9761
Mailing Address - Country:US
Mailing Address - Phone:231-369-2656
Mailing Address - Fax:
Practice Address - Street 1:4713 PINE ST SW
Practice Address - Street 2:
Practice Address - City:S BOARDMAN
Practice Address - State:MI
Practice Address - Zip Code:49680-9761
Practice Address - Country:US
Practice Address - Phone:231-369-2656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069428207Q00000X
MI5601003799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty