Provider Demographics
NPI:1831656289
Name:WEAVER, BRIANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S HOLLISTON AVE APT 209
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2641
Mailing Address - Country:US
Mailing Address - Phone:951-852-3971
Mailing Address - Fax:
Practice Address - Street 1:399 E HIGHLAND AVE STE 319
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3858
Practice Address - Country:US
Practice Address - Phone:909-881-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant