Provider Demographics
NPI:1821051079
Name:GARRETT, ANDREA L (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:GARRETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:L
Other - Last Name:SLAUGHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:866-630-9882
Mailing Address - Fax:920-682-5810
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:STE 180
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8657
Practice Address - Country:US
Practice Address - Phone:314-878-5599
Practice Address - Fax:314-392-4290
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009017535207ND0101X, 207N00000X
WI48976-020207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34902400Medicaid
WI143254340Medicare PIN
WI101574150Medicare PIN
WIP00432252Medicare PIN
WI60695OtherDEAN HEALTH INSURANCE