Healthcare Provider Details

I. General information

NPI: 1629841721
Provider Name (Legal Business Name): SAMUEL MBAKI MOKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S 9TH ST
DE PERE WI
54115-3919
US

IV. Provider business mailing address

119 N JACKSON ST
GREEN BAY WI
54301-4934
US

V. Phone/Fax

Practice location:
  • Phone: 715-582-2247
  • Fax: 920-983-5174
Mailing address:
  • Phone: 214-616-7318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4122-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: