Provider Demographics
NPI:1235526526
Name:WEAVER, MELISSA KAY
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:KAY
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 W NEWBERRY RD STE 210
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-6602
Mailing Address - Country:US
Mailing Address - Phone:352-331-3583
Mailing Address - Fax:352-331-3669
Practice Address - Street 1:3100 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4613
Practice Address - Country:US
Practice Address - Phone:407-303-7283
Practice Address - Fax:407-303-0473
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9108803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015422100Medicaid
FLIH036ZMedicare PIN