Provider Demographics
NPI:1104988328
Name:WEAVER, BRIAN SHANKLIN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:SHANKLIN
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5203
Mailing Address - Country:US
Mailing Address - Phone:704-377-5772
Mailing Address - Fax:
Practice Address - Street 1:814 KEMPSVILLE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4001
Practice Address - Country:US
Practice Address - Phone:757-455-8887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT186418207L00000X
VA0101245237207LP2900X, 208VP0014X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00918125OtherRAILROAD MEDICARE
NC5911825Medicaid
NC5911825Medicaid
VAVV0436AMedicare PIN