Provider Demographics
NPI:1477043057
Name:SAMPSON, ALEXIS MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MARIE
Last Name:SAMPSON
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 1:2000 W MAIN ST STE M
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1773
Mailing Address - Country:US
Mailing Address - Phone:630-584-9242
Mailing Address - Fax:
Practice Address - Street 1:2000 W MAIN ST STE M
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1773
Practice Address - Country:US
Practice Address - Phone:630-584-9242
Practice Address - Fax:630-584-9243
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006584363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant