Basic Information
Provider Information | |||||||||
NPI: | 1073773685 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEAVER | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 100174 | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292023174 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645122830 | ||||||||
FaxNumber: | 8645122830 | ||||||||
Practice Location | |||||||||
Address1: | 800 N FANT ST | ||||||||
Address2: |   | ||||||||
City: | ANDERSON | ||||||||
State: | SC | ||||||||
PostalCode: | 296215708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645121340 | ||||||||
FaxNumber: | 8645121749 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2008 | ||||||||
LastUpdateDate: | 09/13/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 3627 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 201954152A | 05 | GA |   | MEDICAID | 20083070 | 01 | SC | SELECT HEALTH | OTHER | AN1705 | 05 | SC |   | MEDICAID | NPI #/SSN# | 01 | SC | TRICARE | OTHER | P00728491 | 01 | SC | RAILROAD MEDICARE | OTHER |