Provider Demographics
NPI:1932653516
Name:DOLAN, TIMOTHY MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:DOLAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8575 YELLOWSTONE DR
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61010-9769
Mailing Address - Country:US
Mailing Address - Phone:815-234-4185
Mailing Address - Fax:
Practice Address - Street 1:2202 HARLEM RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-2754
Practice Address - Country:US
Practice Address - Phone:815-877-4848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041327743163W00000X
WI197396-30163W00000X
IL209014799367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse