Provider Demographics
NPI:1659854677
Name:BOARDMAN, JAY (PA-C)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:BOARDMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14109 N 83RD AVE APT 329
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4779
Mailing Address - Country:US
Mailing Address - Phone:469-693-2144
Mailing Address - Fax:
Practice Address - Street 1:13755 N LITCHFIELD RD STE 105
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-4288
Practice Address - Country:US
Practice Address - Phone:623-322-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
AZ7273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical