Provider Demographics
NPI:1285390302
Name:WEAVER, HALEY (PA)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 AZTEC DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4003
Mailing Address - Country:US
Mailing Address - Phone:303-668-7734
Mailing Address - Fax:
Practice Address - Street 1:1107 ASSEMBLY DR STE D-160
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-4806
Practice Address - Country:US
Practice Address - Phone:303-668-7734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114691363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant