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:M
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:PO BOX 2039
Mailing Address - Street 2:
Mailing Address - City:RUNNING SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92382-2039
Mailing Address - Country:US
Mailing Address - Phone:818-754-7321
Mailing Address - Fax:
Practice Address - Street 1:340 S LEMON AVE # 9892
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2706
Practice Address - Country:US
Practice Address - Phone:415-403-2156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-06-15
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