Provider Demographics
NPI:1336959824
Name:BOARDMAN, MARCUS
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:BOARDMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 SHAFFER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5761
Mailing Address - Country:US
Mailing Address - Phone:831-466-9307
Mailing Address - Fax:
Practice Address - Street 1:1201 SHAFFER RD STE 1
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-5761
Practice Address - Country:US
Practice Address - Phone:831-466-9307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion