Provider Demographics
NPI:1326668492
Name:KYROUAC, LAUREN VICTORIA
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:VICTORIA
Last Name:KYROUAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 PATRIOT BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8039
Mailing Address - Country:US
Mailing Address - Phone:847-535-8500
Mailing Address - Fax:847-998-9303
Practice Address - Street 1:2701 PATRIOT BLVD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8039
Practice Address - Country:US
Practice Address - Phone:847-535-8500
Practice Address - Fax:847-998-9303
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-19
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008171363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant