Individual
BETH SCOGGAN COSTOLNICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
550 PROFESSIONAL DR, MACON, GA 31201-1411
(478) 741-3007
(478) 755-1547
Mailing address
550 PROFESSIONAL DR, MACON, GA 31201-1411
(478) 741-3007
(478) 755-1547
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
1094738
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
582409645
TAXPAYER IDENTIFICATION NUMBER
GA
Enumeration date
09/14/2010
Last updated
03/27/2012
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