Provider Demographics
NPI:1114335353
Name:MARLEY, DUSTIN (PA-C)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:MARLEY
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 1:676 N SAINT CLAIR ST STE 940
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2945
Mailing Address - Country:US
Mailing Address - Phone:312-926-8358
Mailing Address - Fax:312-926-9630
Practice Address - Street 1:676 N SAINT CLAIR ST STE 940
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2945
Practice Address - Country:US
Practice Address - Phone:312-926-8358
Practice Address - Fax:312-926-9630
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
IL085010476363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ169943OtherMEDICARE PTAN
AZ941934Medicaid