Provider Demographics
NPI:1164699344
Name:TROFIMENKO, MICHAEL A (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:TROFIMENKO
Suffix:
Gender:M
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 1:632 W GIBSON RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-5169
Mailing Address - Country:US
Mailing Address - Phone:530-668-2600
Mailing Address - Fax:530-661-2410
Practice Address - Street 1:632 W GIBSON RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-5169
Practice Address - Country:US
Practice Address - Phone:530-668-2600
Practice Address - Fax:530-661-2410
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19189363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ13239ZMedicare PIN
CAAN948XMedicare PIN