Provider Demographics
NPI:1588894182
Name:VANSELOW, LAURA M (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:VANSELOW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:M
Other - Last Name:ASSMUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2650 WARRENVILLE RD
Mailing Address - Street 2:STE. 280
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515
Mailing Address - Country:US
Mailing Address - Phone:630-324-7900
Mailing Address - Fax:630-271-1813
Practice Address - Street 1:3231 S EUCLID
Practice Address - Street 2:STE. 400
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402
Practice Address - Country:US
Practice Address - Phone:708-783-0244
Practice Address - Fax:708-783-0287
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.002209363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1054932OtherNCCPA