Provider Demographics
NPI:1255856845
Name:WEAVER, RYAN G (LO, ABOC, NCLEC)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:G
Last Name:WEAVER
Suffix:
Gender:M
Credentials:LO, ABOC, NCLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-2424
Mailing Address - Country:US
Mailing Address - Phone:860-630-4634
Mailing Address - Fax:860-928-4975
Practice Address - Street 1:625 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2424
Practice Address - Country:US
Practice Address - Phone:860-630-4634
Practice Address - Fax:860-928-4975
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1758156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician