Healthcare Provider Details

I. General information

NPI: 1114335353
Provider Name (Legal Business Name): DUSTIN MARLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 940
CHICAGO IL
60611-2945
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 940
CHICAGO IL
60611-2945
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-8358
  • Fax: 312-926-9630
Mailing address:
  • Phone: 312-926-8358
  • Fax: 312-926-9630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085010476
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: