Provider Demographics
NPI:1194005090
Name:WEAVER, MARK ALEXANDER (MAED, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALEXANDER
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MAED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1769
Mailing Address - Country:US
Mailing Address - Phone:731-445-7413
Mailing Address - Fax:
Practice Address - Street 1:325 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1769
Practice Address - Country:US
Practice Address - Phone:731-352-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer