Basic Information
| Provider Information | |||||||||
| NPI: | 1619964012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILAM | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 WESTERN AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720344967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013276665 | ||||||||
| FaxNumber: | 5017300289 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 WESTERN AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720344967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013276665 | ||||||||
| FaxNumber: | 5017300289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 12/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | C01353 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 146260701 | 05 | AR | MEDICAID |