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NPI Code Detail

MEDICARE: JEREMY BLAKE WEAVER P.A.

MEDICARE: JEREMY BLAKE WEAVER P.A.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantPA06492TX
2363A00000XPhysician AssistantPA-843AR

General Provider Information

NPI Number : 1790014447
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEREMY BLAKE WEAVER P.A.
Provider Business Mailing Address
First Line : 620 BROADWAY ST
Second Line :
City : VAN BUREN
State : AR
Zip : 72956-5830
Country : US
Telephone Number : 479-474-5061
Fax Number : 479-922-2007
Provider Business Practice Location Address
First Line : 620 BROADWAY ST
Second Line :
City : VAN BUREN
State : AR
Zip : 72956-5830
Country : US
Telephone Number : 479-474-5061
Fax Number : 479-922-2007
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/09/2009
Last Update Date : 01/26/2021

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