Healthcare Provider Details

I. General information

NPI: 1144965815
Provider Name (Legal Business Name): SAMANTHA O'BRIEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 W ANTHONY DR
URBANA IL
61802-7431
US

IV. Provider business mailing address

810 W ANTHONY DR
URBANA IL
61802-7431
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3077
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011093
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: