Healthcare Provider Details

I. General information

NPI: 1336994110
Provider Name (Legal Business Name): STAN MOKOKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1695 S SAN JACINTO AVE STE A
SAN JACINTO CA
92583-5103
US

IV. Provider business mailing address

36056 DARCY PL
MURRIETA CA
92562-4563
US

V. Phone/Fax

Practice location:
  • Phone: 951-330-3100
  • Fax:
Mailing address:
  • Phone: 912-272-4640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1983
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number102105
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: