Provider Demographics
NPI:1104320308
Name:WEAVER, DALTON GLENN
Entity type:Individual
Prefix:
First Name:DALTON
Middle Name:GLENN
Last Name:WEAVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-6203
Mailing Address - Country:US
Mailing Address - Phone:731-300-4232
Mailing Address - Fax:
Practice Address - Street 1:708 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-4829
Practice Address - Country:US
Practice Address - Phone:731-394-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN028076OtherSTATE VOLUNTEER MUTUAL INSURANCE COMPANY (SVMIC)