Healthcare Provider Details

I. General information

NPI: 1336622646
Provider Name (Legal Business Name): MARISA KRISANANUWATARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 METRIC BLVD
AUSTIN TX
78758-8616
US

IV. Provider business mailing address

6805 LA SALLE DR
AUSTIN TX
78723-2211
US

V. Phone/Fax

Practice location:
  • Phone: 512-228-3300
  • Fax:
Mailing address:
  • Phone: 151-258-7447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2113050
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: