Healthcare Provider Details

I. General information

NPI: 1003523192
Provider Name (Legal Business Name): KOALAT ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19010 STONE OAK PKWY
SAN ANTONIO TX
78258-3225
US

IV. Provider business mailing address

3301 S 14TH ST STE 16180
ABILENE TX
79605-5015
US

V. Phone/Fax

Practice location:
  • Phone: 210-575-5200
  • Fax:
Mailing address:
  • Phone: 325-660-5535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MELISSA ANN WATERMAN
Title or Position: CRNA, OWNER
Credential: CRNA
Phone: 325-660-5535