Provider Demographics
NPI:1619967031
Name:WEAVER, AMY (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1675
Mailing Address - Country:US
Mailing Address - Phone:260-432-4400
Mailing Address - Fax:260-969-6898
Practice Address - Street 1:7988 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-432-4400
Practice Address - Fax:260-969-6898
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001422A363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200338310Medicaid
INP11373Medicare UPIN
IN259990WMedicare PIN
INP11373Medicare UPIN