Provider Demographics
NPI:1417081118
Name:WEAVER, PAMELA (CDM)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 874553
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-4553
Mailing Address - Country:US
Mailing Address - Phone:907-373-2672
Mailing Address - Fax:907-373-3672
Practice Address - Street 1:231 E SWANSON
Practice Address - Street 2:SUITE # 26
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99687
Practice Address - Country:US
Practice Address - Phone:907-373-2672
Practice Address - Fax:907-373-3672
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA3176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNM0032Medicaid