Provider Demographics
NPI:1174730519
Name:COOPER, TANA KATHRYN (DO)
Entity type:Individual
Prefix:DR
First Name:TANA
Middle Name:KATHRYN
Last Name:COOPER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:967 CEDAR LAKE RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2128
Practice Address - Country:US
Practice Address - Phone:228-205-6814
Practice Address - Fax:228-392-0864
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS20540204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05384293Medicaid