Provider Demographics
NPI:1619123494
Name:WEAVER, MELANIE K (PA-C)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:K
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 1:3200 MACCORKLE AVE SE STE B16
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1227
Mailing Address - Country:US
Mailing Address - Phone:304-388-5848
Mailing Address - Fax:304-388-9654
Practice Address - Street 1:3200 MACCORKLE AVE SE STE B16
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-5848
Practice Address - Fax:304-388-9654
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07834363A00000X
WV01371363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVB441OtherGROUP MEDICARE
WV3810024049OtherGROUP MEDICAID
WV1619123494OtherTHSPP MEDICAID REFERRING PROVIDER
WV3810024049OtherGROUP MEDICAID