Provider Demographics
NPI:1265861793
Name:WEAVER, BROOKE REBA (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:REBA
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:REBA
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 570
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1579
Mailing Address - Country:US
Mailing Address - Phone:614-293-3600
Mailing Address - Fax:614-293-2910
Practice Address - Street 1:2835 FRED TAYLOR DR STE 2000
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-1552
Practice Address - Country:US
Practice Address - Phone:614-293-3600
Practice Address - Fax:614-293-2910
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003817RX363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0111538Medicaid
OH0111538Medicaid