Provider Demographics
NPI:1982215430
Name:WEAVER, ISAAC MATTHEW SHEPARD (RN)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:MATTHEW SHEPARD
Last Name:WEAVER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 PARSLEY ST
Mailing Address - Street 2:
Mailing Address - City:UNICOI
Mailing Address - State:TN
Mailing Address - Zip Code:37692-4110
Mailing Address - Country:US
Mailing Address - Phone:423-534-5328
Mailing Address - Fax:
Practice Address - Street 1:809 LAMONT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5453
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN202308163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical