Provider Demographics
NPI:1619964012
Name:MILAM, TERRY TODD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:TODD
Last Name:MILAM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:525 WESTERN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4967
Mailing Address - Country:US
Mailing Address - Phone:501-327-6665
Mailing Address - Fax:501-730-0289
Practice Address - Street 1:525 WESTERN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4967
Practice Address - Country:US
Practice Address - Phone:501-327-6665
Practice Address - Fax:501-730-0289
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC01353367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146260701Medicaid
AR146260701Medicaid