MEDICARE: VEDWATTIE D KOOMA

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	164W00000X	Licensed Practical Nurse	163458	TX

General Provider Information

NPI Number	:	1265620736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VEDWATTIE D KOOMA

Provider Business Mailing Address
First Line	:	3130 BIRKHEAD DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78234-2565
Country	:	US
Telephone Number	:	210-824-1268
Fax Number	:	210-824-1268

Provider Business Practice Location Address
First Line	:	3130 BIRKHEAD DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78234-2565
Country	:	US
Telephone Number	:	210-824-1268
Fax Number	:	210-824-1268

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2007
Last Update Date	:	10/10/2007

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