Provider Demographics
NPI:1790886786
Name:SWEENEY, JOHN RAYMOND (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RAYMOND
Last Name:SWEENEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1059
Mailing Address - Country:US
Mailing Address - Phone:760-568-2684
Mailing Address - Fax:760-837-2264
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:HARRY & DIANE RINKER BUILDING
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-568-2684
Practice Address - Fax:760-837-2264
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20271363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20271OtherCA LICENSE #
CAS17302Medicare UPIN
CA0PA202710Medicare PIN