Healthcare Provider Details

I. General information

NPI: 1104754795
Provider Name (Legal Business Name): MATTHEW DAVID THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 SCHEURING RD
DE PERE WI
54115-1701
US

IV. Provider business mailing address

136 W MAIN ST
COLEMAN WI
54112-9703
US

V. Phone/Fax

Practice location:
  • Phone: 920-336-5754
  • Fax: 920-336-2978
Mailing address:
  • Phone: 920-883-7677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: