Provider Demographics
NPI:1770504102
Name:MOONEY, RAYMOND P (PA-C)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:P
Last Name:MOONEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-9703
Mailing Address - Country:US
Mailing Address - Phone:517-592-3275
Mailing Address - Fax:517-592-2540
Practice Address - Street 1:107 CHICAGO ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-9703
Practice Address - Country:US
Practice Address - Phone:517-592-3275
Practice Address - Fax:517-592-2540
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP0107001Medicare ID - Type Unspecified
MI226318Medicare UPIN