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 1:901 MCCLINTOCK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0872
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:
Practice Address - Street 1:13055 W MCDOWELL RD
Practice Address - Street 2:BUILDING E, STE 109
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-6449
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ941934Medicaid
AZZ169943OtherMEDICARE PTAN