Provider Demographics
NPI:1316984149
Name:GARRISON, ANDREA KOOSNE (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:KOOSNE
Last Name:GARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 BRIAR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-5963
Mailing Address - Country:US
Mailing Address - Phone:662-690-4200
Mailing Address - Fax:
Practice Address - Street 1:4577 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6590
Practice Address - Country:US
Practice Address - Phone:662-377-7590
Practice Address - Fax:662-377-7595
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS170692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08226071Medicaid
MS260000626Medicare ID - Type Unspecified
MS08226071Medicaid