Provider Demographics
NPI:1104882844
Name:WEIS, TAMARA JEAN
Entity type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:JEAN
Last Name:WEIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:MARKOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8908
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC053088367500000X
VA0024164951367500000X
SC19381367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1104882844Medicaid
NC562014989OtherTRICARE
NC6907604Medicaid
VA011488F81Medicare PIN
NC6907604Medicaid
VA011488F81Medicare PIN