Provider Demographics
NPI:1124175872
Name:TRUPKE, TIMOTHY (PT, ATC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:TRUPKE
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3852 CREAMERY RD
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-9210
Mailing Address - Country:US
Mailing Address - Phone:920-338-9670
Mailing Address - Fax:920-338-9680
Practice Address - Street 1:3852 CREAMERY RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9210
Practice Address - Country:US
Practice Address - Phone:920-338-9670
Practice Address - Fax:920-338-9680
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
WI5384-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40347200Medicaid
WI5384-024OtherPHYSICAL THERAPY LICENSE
901497OtherNATA MEMBER #