Provider Demographics
NPI:1013575034
Name:MUKETE, TAMARA (DPT, PT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MUKETE
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 CRAIN HWY S STE 401
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6413
Mailing Address - Country:US
Mailing Address - Phone:410-768-5050
Mailing Address - Fax:410-768-7830
Practice Address - Street 1:15301 GROVE CIR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4475
Practice Address - Country:US
Practice Address - Phone:952-993-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27712225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist