Healthcare Provider Details

I. General information

NPI: 1124404892
Provider Name (Legal Business Name): CONSTANCE WEAVER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CONSTANCE WAGNER

II. Dates (important events)

Enumeration Date: 08/05/2015
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SW 62ND BLVD SUITE C
GAINESVILLE FL
32607-6030
US

IV. Provider business mailing address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-9465
  • Fax: 352-265-9466
Mailing address:
  • Phone: 352-265-9465
  • Fax: 352-265-9466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108835
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: