Provider Demographics
NPI:1528050457
Name:MANNEY, PAUL T (PA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:MANNEY
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 2110
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92263-2110
Mailing Address - Country:US
Mailing Address - Phone:760-778-1660
Mailing Address - Fax:760-778-1662
Practice Address - Street 1:1180 N INDIAN CANYON DR
Practice Address - Street 2:SUITE W-201
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4800
Practice Address - Country:US
Practice Address - Phone:760-416-4511
Practice Address - Fax:760-416-4512
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13404363AM0700X, 363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA134040Medicare PIN
CAP05147Medicare UPIN