Provider Demographics
NPI:1922204130
Name:BARKER, ANDREA KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:KELLY
Last Name:BARKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-575-1194
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:1340 BROAD AVE STE 220
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2465
Practice Address - Country:US
Practice Address - Phone:228-575-1300
Practice Address - Fax:228-867-6423
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-1879208600000X
NE280212086S0129X
MS212862086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1922201430Medicaid