Healthcare Provider Details

I. General information

NPI: 1902576903
Provider Name (Legal Business Name): SHAKUUR ISSA CAWAALE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 W LAPHAM BLVD APT 301
MILWAUKEE WI
53204-3437
US

IV. Provider business mailing address

921 W LAPHAM BLVD APT 301
MILWAUKEE WI
53204-3437
US

V. Phone/Fax

Practice location:
  • Phone: 414-299-9564
  • Fax:
Mailing address:
  • Phone: 414-299-9564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number0038879
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: