Provider Demographics
NPI:1306005897
Name:WEAVER, JEFFREY LEE (PA-C, MMS)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LEE
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PA-C, MMS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-706-2125
Mailing Address - Fax:410-706-3243
Practice Address - Street 1:725 W LOMBARD ST
Practice Address - Street 2:SUITE 163 B
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1009
Practice Address - Country:US
Practice Address - Phone:410-706-2125
Practice Address - Fax:410-706-3243
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03641363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD181937Y2ZMedicare PIN