Provider Demographics
NPI:1639318645
Name:CAUDLE, MARTY (PA)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:
Last Name:CAUDLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 DURLEY ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-1504
Mailing Address - Country:US
Mailing Address - Phone:186-903-5956
Mailing Address - Fax:
Practice Address - Street 1:404 DURLEY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246
Practice Address - Country:US
Practice Address - Phone:618-690-3595
Practice Address - Fax:618-690-3596
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4854363A00000X
ORPA01451363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant