Provider Demographics
NPI:1447872494
Name:WEIR, MICHAEL BLAKE
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BLAKE
Last Name:WEIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 CHIEF STAN WAITE DR
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-2134
Mailing Address - Country:US
Mailing Address - Phone:539-777-9965
Mailing Address - Fax:
Practice Address - Street 1:413 CHIEF STAN WAITE DR
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-2134
Practice Address - Country:US
Practice Address - Phone:539-777-9965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider