Provider Demographics
NPI:1124404892
Name:WEAVER, CONSTANCE (PA-C)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-3003
Mailing Address - Country:US
Mailing Address - Phone:352-265-9465
Mailing Address - Fax:352-265-9466
Practice Address - Street 1:200 SW 62ND BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-6030
Practice Address - Country:US
Practice Address - Phone:352-265-9465
Practice Address - Fax:352-265-9466
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015624800Medicaid
FLIH181ZMedicare PIN