Provider Demographics
NPI:1538407903
Name:FEDORENKO, PAUL
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:FEDORENKO
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 1:2204 W CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-2425
Mailing Address - Country:US
Mailing Address - Phone:916-572-0811
Mailing Address - Fax:916-572-0813
Practice Address - Street 1:2204 W CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-2425
Practice Address - Country:US
Practice Address - Phone:916-572-0811
Practice Address - Fax:916-572-0813
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-19
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14279174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist