Provider Demographics
NPI:1578527412
Name:WEAVER, KENNETH LEON (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEON
Last Name:WEAVER
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 NORTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72118-5297
Mailing Address - Country:US
Mailing Address - Phone:501-663-6455
Mailing Address - Fax:501-663-4877
Practice Address - Street 1:5220 NORTHSHORE DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72118-5297
Practice Address - Country:US
Practice Address - Phone:501-663-6455
Practice Address - Fax:501-663-4877
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA214363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR199358795Medicaid
AR5C201P195Medicare PIN