Healthcare Provider Details

I. General information

NPI: 1982215430
Provider Name (Legal Business Name): ISAAC MATTHEW SHEPARD WEAVER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 LAMONT ST
JOHNSON CITY TN
37604-5453
US

IV. Provider business mailing address

224 PARSLEY ST
UNICOI TN
37692-4110
US

V. Phone/Fax

Practice location:
  • Phone: 423-926-1171
  • Fax:
Mailing address:
  • Phone: 423-534-5328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number202308
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: