Healthcare Provider Details

I. General information

NPI: 1235687773
Provider Name (Legal Business Name): DENNIS MARK WEAVER JR. CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

4301 W MARKHAM ST
LITTLE ROCK AR
72205-7101
US

V. Phone/Fax

Practice location:
  • Phone: 501-837-8859
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA004762
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: