Provider Demographics
NPI:1275384414
Name:SERIKOV, YEVGENIY
Entity Type:Individual
Prefix:
First Name:YEVGENIY
Middle Name:
Last Name:SERIKOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4541 PONY EXPRESS TRL
Mailing Address - Street 2:
Mailing Address - City:CAMINO
Mailing Address - State:CA
Mailing Address - Zip Code:95709-9613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4541 PONY EXPRESS TRL
Practice Address - Street 2:
Practice Address - City:CAMINO
Practice Address - State:CA
Practice Address - Zip Code:95709-9613
Practice Address - Country:US
Practice Address - Phone:916-247-4201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95367401364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist