Individual
MS. STACY W WEAVER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.
Contact information
Practice address
1619 CAROLINA AVE, ORANGEBURG, SC 29115-4939
(803) 537-7474
(803) 531-7457
Mailing address
PO BOX 1245, ORANGEBURG, SC 29116-1245
(803) 395-4561
(803) 395-2237
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
1829
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
018
BLUE CROSS BLUE SHIELD / BLUE CHOICE
SC
05
—
GP5343
—
SC
Enumeration date
09/26/2012
Last updated
04/23/2013
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