Healthcare Provider Details

I. General information

NPI: 1083301956
Provider Name (Legal Business Name): OLIVIA PAIGE WEAVER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6151 N MAIN STREET RD
WEBB CITY MO
64870-8189
US

IV. Provider business mailing address

6151 N MAIN STREET RD
WEBB CITY MO
64870-8189
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-0408
  • Fax:
Mailing address:
  • Phone: 417-781-0408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2024028622
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: