Provider Demographics
NPI:1962022020
Name:KOENIG, MICHAEL (DNP, CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KOENIG
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 DEXTER LAKE DR APT 304
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-1320
Mailing Address - Country:US
Mailing Address - Phone:615-775-4115
Mailing Address - Fax:
Practice Address - Street 1:1614 DEXTER LAKE DR APT 304
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-1320
Practice Address - Country:US
Practice Address - Phone:615-775-4115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-19
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN208343163W00000X
TN27694367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse