Healthcare Provider Details

I. General information

NPI: 1336603679
Provider Name (Legal Business Name): MEGHAN WEAVER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGHAN SHELTON

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 MAIN ST
PIKEVILLE TN
37367-5319
US

IV. Provider business mailing address

PO BOX 308
BENTON TN
37307-0308
US

V. Phone/Fax

Practice location:
  • Phone: 423-447-6287
  • Fax:
Mailing address:
  • Phone: 423-338-8995
  • Fax: 423-338-8996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3744
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: