Provider Demographics
NPI:1225229156
Name:AGAN, TIMMY JAY (MS, AT,C)
Entity Type:Individual
Prefix:MR
First Name:TIMMY
Middle Name:JAY
Last Name:AGAN
Suffix:
Gender:M
Credentials:MS, AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 REHOBOTH RD SW
Mailing Address - Street 2:
Mailing Address - City:CAVE SPRING
Mailing Address - State:GA
Mailing Address - Zip Code:30124-2974
Mailing Address - Country:US
Mailing Address - Phone:770-877-1016
Mailing Address - Fax:770-382-8883
Practice Address - Street 1:306 REHOBOTH RD SW
Practice Address - Street 2:
Practice Address - City:CAVE SPRING
Practice Address - State:GA
Practice Address - Zip Code:30124-2974
Practice Address - Country:US
Practice Address - Phone:770-877-1016
Practice Address - Fax:770-382-8883
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0000772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0000077OtherGEORGIA BOARD OF ATHLETIC