Provider Demographics
NPI:1801088679
Name:WEAVER, MATTHEW GARRETT (CRNA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GARRETT
Last Name:WEAVER
Suffix:
Gender:M
Credentials:CRNA
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Mailing Address - Street 1:4100 INTERNATIONAL PLAZA
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109
Mailing Address - Country:US
Mailing Address - Phone:817-224-0530
Mailing Address - Fax:817-877-0350
Practice Address - Street 1:1502 E 17TH ST
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TX
Practice Address - Zip Code:79556-1734
Practice Address - Country:US
Practice Address - Phone:325-721-7416
Practice Address - Fax:325-235-1701
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX671037367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX072555OtherCRNA CERTIFICATION
TX671037OtherLICENSE #