Provider Demographics
NPI:1356456628
Name:WEAVER, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
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 1:201 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-4211
Mailing Address - Country:US
Mailing Address - Phone:843-857-0111
Mailing Address - Fax:
Practice Address - Street 1:999 CHERAW ST
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-2420
Practice Address - Country:US
Practice Address - Phone:843-479-2341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN1313363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0466Medicaid
SCP00906535OtherRAILROAD MEDICARE PTAN
SCSC34771849Medicare PIN
SCP00906535OtherRAILROAD MEDICARE PTAN
SCSC34771162Medicare PIN
SCNP0466Medicaid
SCSC34774784Medicare PIN
SCP25299Medicare UPIN
SCSC34777977Medicare PIN
SCSC34771850Medicare PIN