Basic Information
| Provider Information | |||||||||
| NPI: | 1801088679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | GARRETT | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 INTERNATIONAL PLAZA | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172240530 | ||||||||
| FaxNumber: | 8178770350 | ||||||||
| Practice Location | |||||||||
| Address1: | 1502 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | SWEETWATER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795561734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3257217416 | ||||||||
| FaxNumber: | 3252351701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 08/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 671037 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 072555 | 01 | TX | CRNA CERTIFICATION | OTHER | 671037 | 01 | TX | LICENSE # | OTHER |