Provider Demographics
NPI:1518230929
Name:WEAVER, CASEY MICHELLE (PA)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:MICHELLE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:MICHELLE
Other - Last Name:DEMENT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:180 GREENE 7502 RD
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-6275
Mailing Address - Country:US
Mailing Address - Phone:870-219-5808
Mailing Address - Fax:
Practice Address - Street 1:1110 W KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4164
Practice Address - Country:US
Practice Address - Phone:870-205-2000
Practice Address - Fax:870-205-2029
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012005135363A00000X
363A00000X
ARPA-495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant