Provider Demographics
NPI:1982081485
Name:DEREK S WEAVER DO PLLC
Entity Type:Organization
Organization Name:DEREK S WEAVER DO PLLC
Other - Org Name:WEAVER FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-837-0070
Mailing Address - Street 1:2935 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-8931
Mailing Address - Country:US
Mailing Address - Phone:509-837-0070
Mailing Address - Fax:509-837-0690
Practice Address - Street 1:2935 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-8931
Practice Address - Country:US
Practice Address - Phone:509-837-0070
Practice Address - Fax:509-837-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60139736207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2045212Medicaid
WA2045212Medicaid
WA50-3923Medicare PIN