Provider Demographics
NPI:1245868496
Name:WEAVER, JUSTIN MARK (PA-C)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MARK
Last Name:WEAVER
Suffix:
Gender:M
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 1:336 EVERLY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ARIEL
Mailing Address - State:PA
Mailing Address - Zip Code:18436-5730
Mailing Address - Country:US
Mailing Address - Phone:973-803-6908
Mailing Address - Fax:
Practice Address - Street 1:1592 ROUTE 739
Practice Address - Street 2:
Practice Address - City:DINGMANS FERRY
Practice Address - State:PA
Practice Address - Zip Code:18328-3513
Practice Address - Country:US
Practice Address - Phone:570-828-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA005167363A00000X
PAMA061373363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant