Provider Demographics
NPI:1518230929
Name:WEAVER, CASEY MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:MICHELLE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:MICHELLE
Other - Last Name:DEMENT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1312 1ST ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2526
Mailing Address - Country:US
Mailing Address - Phone:573-559-2780
Mailing Address - Fax:
Practice Address - Street 1:1312 1ST ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2526
Practice Address - Country:US
Practice Address - Phone:573-559-2780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012005135363A00000X, 363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant