Healthcare Provider Details

I. General information

NPI: 1326766627
Provider Name (Legal Business Name): ALEXEY V KORENICHENKO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ALEKSEY KORENICHENKO

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 01/11/2024
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 W RAHN RD
DAYTON OH
45429-2219
US

IV. Provider business mailing address

33 W RAHN RD
DAYTON OH
45429-2219
US

V. Phone/Fax

Practice location:
  • Phone: 937-433-8990
  • Fax: 937-433-8691
Mailing address:
  • Phone: 937-433-8990
  • Fax: 937-433-8691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007732RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: