Healthcare Provider Details

I. General information

NPI: 1487402251
Provider Name (Legal Business Name): PAVEL MUDRENKO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 HOSPITAL DR
SACRAMENTO CA
95823-5403
US

IV. Provider business mailing address

7500 HOSPITAL DR
SACRAMENTO CA
95823-5403
US

V. Phone/Fax

Practice location:
  • Phone: 916-423-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number64607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: