Provider Demographics
NPI:1972184315
Name:WEAVER, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
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 1:209 GREYSTONE DR
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-9764
Mailing Address - Country:US
Mailing Address - Phone:570-905-5594
Mailing Address - Fax:
Practice Address - Street 1:326 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2740
Practice Address - Country:US
Practice Address - Phone:860-889-8331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-17
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT136407367500000X
MARN10005388367500000X
CT176915163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse