Provider Demographics
NPI:1407942188
Name:WEAVER, ANTHONY D (CRNA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:D
Last Name:WEAVER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47993-1049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:412 N MONROE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:IN
Practice Address - Zip Code:47993-1049
Practice Address - Country:US
Practice Address - Phone:765-762-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704213024367500000X
IN28207816A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4493716Medicaid
MI4493716Medicaid
MI430079721Medicare ID - Type UnspecifiedRAILROAD MEDICARE