Provider Demographics
NPI:1124250055
Name:THOR, THONG P (PA)
Entity type:Individual
Prefix:
First Name:THONG
Middle Name:P
Last Name:THOR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:THONG
Other - Middle Name:P
Other - Last Name:THOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5794
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5970
Practice Address - Street 1:2500 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911
Practice Address - Country:US
Practice Address - Phone:920-830-6788
Practice Address - Fax:920-738-4792
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2538-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI402200017Medicare PIN
WIP00883265Medicare Oscar/Certification
WI401600084Medicare Oscar/Certification
WI078450047Medicare Oscar/Certification
WI711810017Medicare PIN
WI000105Medicare Oscar/Certification