Provider Demographics
NPI:1487939088
Name:BOBURKA, SAMANTHA MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:MARIE
Last Name:BOBURKA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:CULLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:23 W CALENDAR AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6327
Mailing Address - Country:US
Mailing Address - Phone:708-745-5277
Mailing Address - Fax:708-579-2408
Practice Address - Street 1:110 W CALENDAR AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2325
Practice Address - Country:US
Practice Address - Phone:708-745-5277
Practice Address - Fax:708-579-2408
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004138363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid