Provider Demographics
NPI:1164736120
Name:KUMMER, TED CHAN JR (FNP)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:CHAN
Last Name:KUMMER
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6622
Mailing Address - Fax:
Practice Address - Street 1:4545 FULLER DR
Practice Address - Street 2:SUITE 325
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6530
Practice Address - Country:US
Practice Address - Phone:972-870-5511
Practice Address - Fax:972-870-5512
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX739803363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care