Healthcare Provider Details

I. General information

NPI: 1760059703
Provider Name (Legal Business Name): DR. MARISSA COPAS WEAVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 FLORMANN ST
RAPID CITY SD
57701-4679
US

IV. Provider business mailing address

640 FLORMANN ST
RAPID CITY SD
57701-4679
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-3300
  • Fax:
Mailing address:
  • Phone: 605-755-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17712
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17712
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: