Provider Demographics
NPI:1740898279
Name:SIDORENKO, IRINA
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:SIDORENKO
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 1:2311 RIDGE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1718
Mailing Address - Country:US
Mailing Address - Phone:678-656-6819
Mailing Address - Fax:
Practice Address - Street 1:2311 RIDGE FOREST DR
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1718
Practice Address - Country:US
Practice Address - Phone:678-656-6819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20299208600000X
GA20-299363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No208600000XAllopathic & Osteopathic PhysiciansSurgery