MEDICARE: KOALAT ANESTHESIA PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist

General Provider Information

NPI Number	:	1003523192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOALAT ANESTHESIA PLLC

Provider Business Mailing Address
First Line	:	3301 S 14TH ST STE 16180
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79605-5015
Country	:	US
Telephone Number	:	325-660-5535
Fax Number	:

Provider Business Practice Location Address
First Line	:	19010 STONE OAK PKWY
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-3225
Country	:	US
Telephone Number	:	210-575-5200
Fax Number	:

Authorized Official
Title or Position	:	CRNA, OWNER
Name	:	MELISSA ANN WATERMAN
Credential	:	CRNA
Telephone Number	:	325-660-5535

Provider Enumeration Date	:	10/31/2022
Last Update Date	:	12/21/2022

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