Provider Demographics
NPI:1548576754
Name:SIDORENKO, ANDREY IVANOVICH (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREY
Middle Name:IVANOVICH
Last Name:SIDORENKO
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 1:4460 W SHAW AVE # 405
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-6210
Mailing Address - Country:US
Mailing Address - Phone:559-271-7003
Mailing Address - Fax:
Practice Address - Street 1:465 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3320
Practice Address - Country:US
Practice Address - Phone:559-791-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA109622OtherPREMIUM URGENT CARE GRP PTAN