Basic Information
| Provider Information | |||||||||
| NPI: | 1487713897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOONTZ | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 COLUMBIA DR | ||||||||
| Address2: | SUITE A327 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444396 | ||||||||
| FaxNumber: | 8138444972 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 COLUMBIA DR | ||||||||
| Address2: | SUITE A327 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444396 | ||||||||
| FaxNumber: | 8138444972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 9244008 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 308193100 | 05 | FL | MEDICAID | G4161 | 01 | FL | BCBS | OTHER | P00391888 | 01 | FL | MEDICARE RAILROAD | OTHER |