MEDICARE: DR. TANA KATHRYN COOPER DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	20540	MS
2	207Q00000X	Family Medicine Physician	20540	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174730519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TANA KATHRYN COOPER DO

Provider Business Mailing Address
First Line	:	2101 HIGHWAY 90
Second Line	:
City	:	GAUTIER
State	:	MS
Zip	:	39553-5340
Country	:	US
Telephone Number	:	228-497-7576
Fax Number	:	228-497-8869

Provider Business Practice Location Address
First Line	:	967 CEDAR LAKE RD
Second Line	:
City	:	BILOXI
State	:	MS
Zip	:	39532-2128
Country	:	US
Telephone Number	:	228-205-6814
Fax Number	:	228-392-0864

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/27/2022

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