Provider Demographics
NPI:1477915098
Name:WEAVER, KELLY EGAN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:EGAN
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 BROAD ROCK BLVD RICHMOND VA 23224
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23249-4915
Mailing Address - Country:US
Mailing Address - Phone:804-675-5000
Mailing Address - Fax:
Practice Address - Street 1:1201 BROAD ROCK BLVD RICHMOND VA 23224
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-4915
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005235363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical