Provider Demographics
NPI:1285601880
Name:CRAFT-COFFMAN, BERETTA (PA-C)
Entity type:Individual
Prefix:
First Name:BERETTA
Middle Name:
Last Name:CRAFT-COFFMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 BENT CREEK DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-7445
Mailing Address - Country:US
Mailing Address - Phone:706-833-8983
Mailing Address - Fax:
Practice Address - Street 1:125 OAKSIDE CT STE 102
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2498
Practice Address - Country:US
Practice Address - Phone:770-213-8376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004259363AS0400X
FLPA9106348363AS0400X
NVPA2198363AS0400X
NC0010-10058363AS0400X
MSPA00325363AS0400X
SC1199363AS0400X
NVPA0659363AS0400X
TNPA0000001672363AS0400X
TXPA09999363AS0400X
VA0110007147363AS0400X
GA002366363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ09699Medicare UPIN
GA97WCFJMMedicare ID - Type Unspecified
SC0215PAMedicaid
GA100000030AMedicaid