Provider Demographics
NPI:1073773685
Name:WEAVER, AMY M (CRNA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:WEAVER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-2830
Mailing Address - Fax:864-512-2830
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-512-1340
Practice Address - Fax:864-512-1749
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3627367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA201954152AMedicaid
SC20083070OtherSELECT HEALTH
SCAN1705Medicaid
SCNPI #/SSN#OtherTRICARE
SCP00728491OtherRAILROAD MEDICARE
SCQ348185965Medicare PIN
SCP00728491OtherRAILROAD MEDICARE