Provider Demographics
NPI:1548576754
Name:SIDORENKO, ANDREY IVANOVICH (PA-C, DMSC)
Entity type:Individual
Prefix:
First Name:ANDREY
Middle Name:IVANOVICH
Last Name:SIDORENKO
Suffix:
Gender:M
Credentials:PA-C, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:CMR 467 BOX 5991
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09096-1060
Mailing Address - Country:US
Mailing Address - Phone:559-709-1344
Mailing Address - Fax:
Practice Address - Street 1:2615 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2223
Practice Address - Country:US
Practice Address - Phone:559-225-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2025-06-30
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