Healthcare Provider Details

I. General information

NPI: 1225451842
Provider Name (Legal Business Name): MATTHEW LOGAN GARNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST 4TH FLOOR EAST TOWER
TUPELO MS
38801-4934
US

IV. Provider business mailing address

1211 S GLOSTER ST STE A
TUPELO MS
38801-6548
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-7100
  • Fax: 662-377-5736
Mailing address:
  • Phone: 662-767-4200
  • Fax: 626-767-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: