Basic Information
| Provider Information | |||||||||
| NPI: | 1487939088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOBURKA | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CULLEN | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 23 W CALENDAR AVE STE 207 | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605256327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087455277 | ||||||||
| FaxNumber: | 7085792408 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 W CALENDAR AVE | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605252325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087455277 | ||||||||
| FaxNumber: | 7085792408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2011 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085004138 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.