Provider Demographics
NPI:1740598648
Name:COSTOLNICK, BETH SCOGGAN (PA-C)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:SCOGGAN
Last Name:COSTOLNICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:ANNE
Other - Last Name:SCOGGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:550 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1411
Mailing Address - Country:US
Mailing Address - Phone:478-741-3007
Mailing Address - Fax:478-755-1547
Practice Address - Street 1:550 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1411
Practice Address - Country:US
Practice Address - Phone:478-741-3007
Practice Address - Fax:478-755-1547
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1094738363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582409645OtherTAXPAYER IDENTIFICATION NUMBER