Provider Demographics
NPI:1083879373
Name:WEAVER-BAILEY, ELLEN L (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:WEAVER-BAILEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PAGE RD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8749
Mailing Address - Country:US
Mailing Address - Phone:910-295-5511
Mailing Address - Fax:
Practice Address - Street 1:205 PAGE RD
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8749
Practice Address - Country:US
Practice Address - Phone:910-295-9211
Practice Address - Fax:910-235-3428
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00699570OtherRAILROAD MEDICARE
NC8103120Medicaid
2759297Medicare PIN