Healthcare Provider Details

I. General information

NPI: 1285601880
Provider Name (Legal Business Name): BERETTA CRAFT-COFFMAN P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 OAKSIDE CT STE 102
CANTON GA
30114-2498
US

IV. Provider business mailing address

626 BENT CREEK DR
EVANS GA
30809-7445
US

V. Phone/Fax

Practice location:
  • Phone: 770-213-8376
  • Fax:
Mailing address:
  • Phone: 706-833-8983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA.0004259
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9106348
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2198
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-10058
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00325
License Number StateMS
# 6
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1199
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA0659
License Number StateNV
# 8
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA0000001672
License Number StateTN
# 9
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA09999
License Number StateTX
# 10
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110007147
License Number StateVA
# 11
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number002366
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: