=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114717147
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | QUINTIN ALEXANDER WEAVER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2025
-----------------------------------------------------
Last Update Date | 05/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53 W FRANKLIN ST
-----------------------------------------------------
City | WAYNESBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-627-8191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 STAHLMAN RD
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16049-5638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-473-6596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------