Provider Demographics
NPI:1386228799
Name:LAYSTROM, SAMANTHA NICHOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:NICHOLE
Last Name:LAYSTROM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:NICHOLE
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1235 S WHITE OAK DR APT 1635
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-8358
Mailing Address - Country:US
Mailing Address - Phone:478-301-9958
Mailing Address - Fax:
Practice Address - Street 1:9600 GROSS POINT RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1214
Practice Address - Country:US
Practice Address - Phone:847-677-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008351363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant