Provider Demographics
NPI:1811623549
Name:WEAVER, JEREMY MICHAEL (RN,APNP)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:MICHAEL
Last Name:WEAVER
Suffix:
Gender:M
Credentials:RN,APNP
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 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:923 ELIZA ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3234
Practice Address - Country:US
Practice Address - Phone:920-965-4800
Practice Address - Fax:920-965-4801
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13109-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
F07220382OtherAMERICAN ACADEMY NURSE PRACTITIONERS