Provider Demographics
NPI:1619900321
Name:MOMAN, ANDREA A (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:A
Last Name:MOMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:M
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:229 SAINT JOHN LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-3276
Mailing Address - Country:US
Mailing Address - Phone:985-249-5600
Mailing Address - Fax:985-893-8272
Practice Address - Street 1:1100 HIGHWAY 16 E
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-4222
Practice Address - Country:US
Practice Address - Phone:601-267-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15206207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121038Medicaid
MSG64037Medicare UPIN