Healthcare Provider Details

I. General information

NPI: 1124175872
Provider Name (Legal Business Name): TIMOTHY TRUPKE PT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3852 CREAMERY RD
DE PERE WI
54115-9210
US

IV. Provider business mailing address

3852 CREAMERY RD
DE PERE WI
54115-9210
US

V. Phone/Fax

Practice location:
  • Phone: 920-338-9670
  • Fax: 920-338-9680
Mailing address:
  • Phone: 920-338-9670
  • Fax: 920-338-9680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5384-024
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: