Healthcare Provider Details

I. General information

NPI: 1275384414
Provider Name (Legal Business Name): YEVGENIY SERIKOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935B SPRING ST
PLACERVILLE CA
95667-4523
US

IV. Provider business mailing address

4541 PONY EXPRESS TRL
CAMINO CA
95709-9613
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-6213
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberRN95367401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: