Provider Demographics
NPI:1730114216
Name:KOONTZ, DONALD M (CRNA)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:M
Last Name:KOONTZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28050 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5919
Mailing Address - Country:US
Mailing Address - Phone:248-471-8720
Mailing Address - Fax:248-471-8966
Practice Address - Street 1:28050 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5919
Practice Address - Country:US
Practice Address - Phone:248-471-8720
Practice Address - Fax:248-471-8966
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704108585367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4438385Medicaid