Healthcare Provider Details

I. General information

NPI: 1780323907
Provider Name (Legal Business Name): TEGAN KOSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TEGAN NOONAN

II. Dates (important events)

Enumeration Date: 06/04/2022
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5502 MARVIN SHIELDS BLVD BLDG 472
APO AA
39503
US

IV. Provider business mailing address

5502 MARVIN SHIELDS BLVD BLDG 472
GULFPORT MS
39503
US

V. Phone/Fax

Practice location:
  • Phone: 228-822-5409
  • Fax:
Mailing address:
  • Phone: 228-822-5409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD91062
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: