Provider Demographics
NPI:1487944286
Name:WEAVER, NICHOLAS (PA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:WEAVER
Suffix:
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 1:329 N HILL ST
Mailing Address - Street 2:
Mailing Address - City:AMITY
Mailing Address - State:AR
Mailing Address - Zip Code:71921-9635
Mailing Address - Country:US
Mailing Address - Phone:870-342-5606
Mailing Address - Fax:870-334-2580
Practice Address - Street 1:329 N HILL ST
Practice Address - Street 2:
Practice Address - City:AMITY
Practice Address - State:AR
Practice Address - Zip Code:71921-9635
Practice Address - Country:US
Practice Address - Phone:870-342-5606
Practice Address - Fax:870-334-2580
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA433363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPA433OtherLICENSES NUMBER
ARMW2324034OtherDEA