Provider Demographics
NPI:1598724197
Name:MILLICAN, TIMOTHY Z (APRN, CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:Z
Last Name:MILLICAN
Suffix:
Gender:M
Credentials:APRN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E RIVER DR
Mailing Address - Street 2:5TH FLOOR C/O IPMS
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3288
Mailing Address - Country:US
Mailing Address - Phone:860-282-0833
Mailing Address - Fax:860-282-0170
Practice Address - Street 1:99 E RIVER DR
Practice Address - Street 2:5TH FLOOR C/O IPMS
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3288
Practice Address - Country:US
Practice Address - Phone:860-282-0833
Practice Address - Fax:860-282-0170
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002573367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004221834Medicaid
CT004221834Medicaid