Provider Demographics
NPI:1689804759
Name:WEAVER, KATRINA LEE (MD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:LEE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5352
Mailing Address - Fax:
Practice Address - Street 1:4348 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0720
Practice Address - Country:US
Practice Address - Phone:540-769-0976
Practice Address - Fax:540-857-5383
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.32264208600000X, 2086S0120X
MO20150209812086S0102X
MTMED-PHYS-LIC-1239872086S0120X
VA0101278072208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Multi-Specialty
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery