Provider Demographics
NPI:1417258856
Name:WEAVER, BROCK ANDREW (DPT)
Entity Type:Individual
Prefix:MR
First Name:BROCK
Middle Name:ANDREW
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 ROUTE 30
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-5518
Mailing Address - Country:US
Mailing Address - Phone:724-532-3422
Mailing Address - Fax:724-532-3424
Practice Address - Street 1:3960 ROUTE 30 STE 104
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-5518
Practice Address - Country:US
Practice Address - Phone:724-532-3422
Practice Address - Fax:724-532-3424
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT020931225100000X
PADAPT002756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007683490007Medicaid
PA1025442830002Medicaid
PA826724OtherHIGHMARK BC/BS