Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | OS004202L | PA |
N | 207ND0101X | MOHS-Micrographic Surgeon | OS004202L | PA |
N | 207NS0135X | Procedural Dermatology | OS004202L | PA |
NPI | 1457344640 |
---|---|
Provider Name | Jeffrey G Weaver |
First Address | Monroeville, PA 15146-2743 |
Second Address | Monroeville, PA 15146-2743 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2005 |
Last Update Date | 12/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0010428650006 | (05) | PA |
070012504 | TRAV. MEDICARE (01) | PA |
097240 | BLUESHIELD (01) | PA |
D98635 | (02) |