Healthcare Provider Details

I. General information

NPI: 1467903674
Provider Name (Legal Business Name): MR. TREVER WEAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W ELK AVE
ELIZABETHTON TN
37643-2654
US

IV. Provider business mailing address

401 E MAIN ST
JOHNSON CITY TN
37601-4877
US

V. Phone/Fax

Practice location:
  • Phone: 423-543-2584
  • Fax: 423-722-2060
Mailing address:
  • Phone: 423-431-0512
  • Fax: 423-722-2060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21987
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: