Provider Demographics
NPI:1023019015
Name:GARRISON-NORTH, NEFRETITI MER-EN-RA (MD)
Entity Type:Individual
Prefix:DR
First Name:NEFRETITI
Middle Name:MER-EN-RA
Last Name:GARRISON-NORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NEFRETITI
Other - Middle Name:MER-EN-RA
Other - Last Name:GARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-5770
Practice Address - Fax:573-331-3974
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011012785208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1042943Medicaid
MO1023019015OtherTRIWEST
LAP00314514OtherRAILROAD MEDICARE PIN
LAP00314514OtherRAILROAD MEDICARE PIN
MO1023019015OtherTRIWEST
MO132470067Medicare PIN