Provider Demographics
NPI:1124995857
Name:JIMENEZ, RAFAEL III (PA)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:JIMENEZ
Suffix:III
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 1:48369 CAMINO MAYA
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-6372
Mailing Address - Country:US
Mailing Address - Phone:760-449-1972
Mailing Address - Fax:
Practice Address - Street 1:47111 MONROE ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6799
Practice Address - Country:US
Practice Address - Phone:760-347-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-17
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA67187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant