Provider Demographics
NPI:1831614700
Name:KURNIK, SAMANTHA J (PA-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:KURNIK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2232 N CLYBOURN AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3193
Mailing Address - Country:US
Mailing Address - Phone:312-633-5841
Mailing Address - Fax:773-269-5500
Practice Address - Street 1:5647 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4403
Practice Address - Country:US
Practice Address - Phone:773-736-1830
Practice Address - Fax:773-736-1840
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-006266363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid