Healthcare Provider Details

I. General information

NPI: 1619964012
Provider Name (Legal Business Name): TERRY TODD MILAM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WESTERN AVE SUITE 201
CONWAY AR
72034-4967
US

IV. Provider business mailing address

525 WESTERN AVE SUITE 201
CONWAY AR
72034-4967
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-6665
  • Fax: 501-730-0289
Mailing address:
  • Phone: 501-327-6665
  • Fax: 501-730-0289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP123726
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC01353
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: