Provider Demographics
NPI:1730220500
Name:WEAVER, BRANDON MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2507
Mailing Address - Country:US
Mailing Address - Phone:315-349-5511
Mailing Address - Fax:315-349-5921
Practice Address - Street 1:510 S 4TH ST STE 140
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2952
Practice Address - Country:US
Practice Address - Phone:315-592-3930
Practice Address - Fax:315-592-3932
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008798-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP86519Medicare UPIN
NYPA0435Medicare ID - Type Unspecified