Provider Demographics
NPI:1609469923
Name:WEAVER, SAMUEL WATSON (PTA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WATSON
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 FLOREY ST
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:618 FLOREY ST
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3502
Practice Address - Country:US
Practice Address - Phone:903-240-6790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2096735225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant