Provider Demographics
NPI:1730440942
Name:WEAVER, KIM PRICE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:PRICE
Last Name:WEAVER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 NEW WALKERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3420
Mailing Address - Country:US
Mailing Address - Phone:336-703-1516
Mailing Address - Fax:
Practice Address - Street 1:2135 NEW WALKERTOWN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3420
Practice Address - Country:US
Practice Address - Phone:336-703-1516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00098363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical