Healthcare Provider Details

I. General information

NPI: 1972095941
Provider Name (Legal Business Name): TREVOR J. WEAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 S BARTON AVE
FRESNO CA
93702-2985
US

IV. Provider business mailing address

496 S BARTON AVE
FRESNO CA
93702-2985
US

V. Phone/Fax

Practice location:
  • Phone: 559-860-4422
  • Fax:
Mailing address:
  • Phone: 559-860-4422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: