Provider Demographics
NPI:1225612468
Name:RILEY, MARCUS WAYNE (FNP-C)
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:WAYNE
Last Name:RILEY
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2068 ORANGE TREE LN STE 215
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4555
Mailing Address - Country:US
Mailing Address - Phone:909-558-4200
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST DEPT OF
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1716
Practice Address - Country:US
Practice Address - Phone:909-558-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016882363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95016882OtherAMERICAN NURSES ASSOCIATION