Basic Information
| Provider Information | |||||||||
| NPI: | 1437212834 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COFFMAN | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 HANDLEY RD STE A | ||||||||
| Address2: | |||||||||
| City: | TYRONE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302902178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709975714 | ||||||||
| FaxNumber: | 7709972844 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 HANDLEY RD STE A | ||||||||
| Address2: | |||||||||
| City: | TYRONE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302902178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709975714 | ||||||||
| FaxNumber: | 7709972844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 002489 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | 002489 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 218131000A | 05 | GA | MEDICAID |