MEDICARE: MR. TIMMY JAY AGAN M.S., A.T.,C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	000077	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000077	OTHER	GA	GEORGIA BOARD OF ATHLETIC

General Provider Information

NPI Number	:	1225229156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMMY JAY AGAN M.S., A.T.,C.

Provider Business Mailing Address
First Line	:	306 REHOBOTH RD SW
Second Line	:
City	:	CAVE SPRING
State	:	GA
Zip	:	30124-2974
Country	:	US
Telephone Number	:	770-877-1016
Fax Number	:	770-382-8883

Provider Business Practice Location Address
First Line	:	306 REHOBOTH RD SW
Second Line	:
City	:	CAVE SPRING
State	:	GA
Zip	:	30124-2974
Country	:	US
Telephone Number	:	770-877-1016
Fax Number	:	770-382-8883

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	08/06/2007

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