Healthcare Provider Details

I. General information

NPI: 1659564458
Provider Name (Legal Business Name): RYAN WEAKLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 COLUMBIA DR J402
TAMPA FL
33606-3508
US

IV. Provider business mailing address

2 COLUMBIA DR J402
TAMPA FL
33606-3508
US

V. Phone/Fax

Practice location:
  • Phone: 813-844-7412
  • Fax:
Mailing address:
  • Phone: 813-844-7412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01073419A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN11253
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number6402
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: