Provider Demographics
NPI:1538831698
Name:DORN, MARQUIS A (PTA)
Entity type:Individual
Prefix:
First Name:MARQUIS
Middle Name:A
Last Name:DORN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28100 TORCH PKWY
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-4026
Mailing Address - Country:US
Mailing Address - Phone:630-413-5800
Mailing Address - Fax:
Practice Address - Street 1:1333 W GUADALUPE RD APT 1215
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-3023
Practice Address - Country:US
Practice Address - Phone:480-689-3231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPTA-012368225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant