Provider Demographics
NPI:1356058358
Name:WEAVIL, MIRANDA JEAN (PA-C)
Entity type:Individual
Prefix:MISS
First Name:MIRANDA
Middle Name:JEAN
Last Name:WEAVIL
Suffix:
Gender:F
Credentials:PA-C
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 935983
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-5983
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-718-5570
Practice Address - Fax:336-718-5569
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-12687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant