Provider Demographics
NPI:1689845000
Name:WEAVER, MARY A
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16724
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80402-6012
Mailing Address - Country:US
Mailing Address - Phone:303-215-5118
Mailing Address - Fax:303-215-5116
Practice Address - Street 1:15400 W 44TH AVE
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80403-7226
Practice Address - Country:US
Practice Address - Phone:303-215-5118
Practice Address - Fax:303-215-5116
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1195960002Medicare NSC