Healthcare Provider Details

I. General information

NPI: 1376488106
Provider Name (Legal Business Name): ANTOINE AKA KOFFI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 RILL DR
AUGUSTA GA
30909-1985
US

IV. Provider business mailing address

717 RILL DR
AUGUSTA GA
30909-1985
US

V. Phone/Fax

Practice location:
  • Phone: 678-200-8506
  • Fax:
Mailing address:
  • Phone: 678-200-8506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN284887
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: