Provider Demographics
NPI:1922040781
Name:BENGE, CORAL ROCHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:CORAL
Middle Name:ROCHELLE
Last Name:BENGE
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 1:1631 HIGHWAY 20 W
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7311
Mailing Address - Country:US
Mailing Address - Phone:678-583-0241
Mailing Address - Fax:678-583-0261
Practice Address - Street 1:1631 HIGHWAY 20 W
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-7311
Practice Address - Country:US
Practice Address - Phone:678-583-0241
Practice Address - Fax:678-583-0261
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ30073Medicare UPIN
GA97WCGBZMedicare ID - Type UnspecifiedMEDICARE NUMBER