Provider Demographics
NPI:1821592940
Name:ADAMOVICH, IRINA P
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:P
Last Name:ADAMOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 ANNADALE LN APT 40
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-2030
Mailing Address - Country:US
Mailing Address - Phone:916-505-4774
Mailing Address - Fax:
Practice Address - Street 1:3900 ANNADALE LN APT 40
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-2030
Practice Address - Country:US
Practice Address - Phone:916-505-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD4440855172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11572585OtherKAISER PERMANENTE