Provider Demographics
NPI:1154359545
Name:MILAM, EDGAR (CRNA)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:MILAM
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:P.O. BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TN
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 SW H K DODGEN LOOP
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1814
Practice Address - Country:US
Practice Address - Phone:254-935-4000
Practice Address - Fax:254-935-4111
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65047367500000X
TNRN65047367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4134284OtherBC
TN3607070Medicare ID - Type UnspecifiedMEDICARE
TN4134284OtherBC