Provider Demographics
NPI:1336767292
Name:FORWARD, MARCUS LARON II (PA-C)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:LARON
Last Name:FORWARD
Suffix:II
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 1:2003 W FULTON ST # 303
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2345
Mailing Address - Country:US
Mailing Address - Phone:312-243-2223
Mailing Address - Fax:
Practice Address - Street 1:4900 N CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-2901
Practice Address - Country:US
Practice Address - Phone:708-456-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085008479363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program