Healthcare Provider Details

I. General information

NPI: 1386196111
Provider Name (Legal Business Name): JOHN WEAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 06/20/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 LINDBLAD AVE.
GIRDWOOD AK
99587-1130
US

IV. Provider business mailing address

PO BOX 1130
GIRDWOOD AK
99587-1130
US

V. Phone/Fax

Practice location:
  • Phone: 907-783-1355
  • Fax:
Mailing address:
  • Phone: 907-783-1355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSWS1281
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: