Basic Information
| Provider Information | |||||||||
| NPI: | 1346206562 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | AMY | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4805 S MOORLAND RD | ||||||||
| Address2: | F&MCW COMMUNITY PHYSICIANS MOORLAND RESERVE | ||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531517401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627987200 | ||||||||
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| Practice Location | |||||||||
| Address1: | N14W23900 STONE RIDGE DR | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531881135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625493030 | ||||||||
| FaxNumber: | 2625747833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 05/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2572 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 38597800 | 05 | WI | MEDICAID |