Provider Demographics
NPI:1417983321
Name:BOARDMAN, ROBERT DAVID (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DAVID
Last Name:BOARDMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 TALMONT CIR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-6059
Mailing Address - Country:US
Mailing Address - Phone:916-666-8315
Mailing Address - Fax:
Practice Address - Street 1:726 4TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5656
Practice Address - Country:US
Practice Address - Phone:530-749-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704179940367500000X
CANA4354367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102971314Medicaid
CA1013013481OtherMEDI-CAL
CA1013013481OtherMEDI-CAL