Provider Demographics
NPI:1962459040
Name:WEAVER-MILLER, KRISTINE A (PA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:A
Last Name:WEAVER-MILLER
Suffix:
Gender:F
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:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:811 AINSWORTH DR STE 109
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-771-5595
Practice Address - Fax:928-771-5596
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5179956-1205363AS0400X
CO3135363AM0700X
AZ4309363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79221513Medicaid
UTD0968Medicaid
CO021673OtherKAISER COMMERCIAL NUMBER
AZ813847Medicaid
AZ813847Medicaid
UTD0968Medicaid
AZZ157979Medicare PIN