=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629841721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL MBAKI MOKE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2023
-----------------------------------------------------
Last Update Date | 11/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 S 9TH ST
-----------------------------------------------------
City | DE PERE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54115-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-582-2247
-----------------------------------------------------
Fax | 920-983-5174
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 N JACKSON ST
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301-4934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-616-7318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 4122-19
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------