Provider Demographics
NPI:1255005211
Name:KEMPKIEWICZ, SAMANTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KEMPKIEWICZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1969 W. OGDEN AVE
Mailing Address - Street 2:CLINIC A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3765
Mailing Address - Country:US
Mailing Address - Phone:312-864-7900
Mailing Address - Fax:312-864-9314
Practice Address - Street 1:1969 W OGDEN AVE
Practice Address - Street 2:CLINIC A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3765
Practice Address - Country:US
Practice Address - Phone:312-864-7900
Practice Address - Fax:312-864-9314
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085.008740363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program