Provider Demographics
NPI:1265674071
Name:WEAVER, DEWAYNE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:LYNN
Last Name:WEAVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 WARNER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-743-3523
Mailing Address - Fax:208-746-8741
Practice Address - Street 1:320 WARNER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-743-3523
Practice Address - Fax:208-746-8741
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60798747207X00000X
IDM-14024207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1265674071Medicaid
ID1265674071Medicaid