Provider Demographics
NPI:1790014447
Name:WEAVER, JEREMY BLAKE (PA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:BLAKE
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-5830
Mailing Address - Country:US
Mailing Address - Phone:479-474-5061
Mailing Address - Fax:479-922-2007
Practice Address - Street 1:620 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-5830
Practice Address - Country:US
Practice Address - Phone:479-474-5061
Practice Address - Fax:479-922-2007
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06492363A00000X
ARPA-843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant