Healthcare Provider Details

I. General information

NPI: 1831060060
Provider Name (Legal Business Name): TEDDY THOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2025
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E EDGEWOOD DR
APPLETON WI
54913-8912
US

IV. Provider business mailing address

900 E EDGEWOOD DR
APPLETON WI
54913-8912
US

V. Phone/Fax

Practice location:
  • Phone: 920-651-5788
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17425-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: