Provider Demographics
NPI:1770887887
Name:MINOR, MARLON (RSA, CSA)
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:
Last Name:MINOR
Suffix:
Gender:M
Credentials:RSA, CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 BOEYKENS PL STE 2A
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 BOEYKENS PL STE 2A
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2152
Practice Address - Country:US
Practice Address - Phone:309-846-4716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000282246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant