Healthcare Provider Details

I. General information

NPI: 1548285570
Provider Name (Legal Business Name): RICKEY GENE WEAVER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGHLINE DR
E WENATCHEE WA
98802-5341
US

IV. Provider business mailing address

820 N CHELAN AVE
WENATCHEE WA
98801-2028
US

V. Phone/Fax

Practice location:
  • Phone: 509-663-8711
  • Fax:
Mailing address:
  • Phone: 509-663-8711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003164
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: