Provider Demographics
NPI:1801949045
Name:WEAVER, MARK L (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1037
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:WY
Mailing Address - Zip Code:82941-1037
Mailing Address - Country:US
Mailing Address - Phone:307-367-6236
Mailing Address - Fax:307-367-3332
Practice Address - Street 1:317 N. FALER AVE
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:WY
Practice Address - Zip Code:82941
Practice Address - Country:US
Practice Address - Phone:307-367-6236
Practice Address - Fax:307-367-3332
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-642225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist