Provider Demographics
NPI:1629841721
Name:MOKE, SAMUEL MBAKI
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:MBAKI
Last Name:MOKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4934
Mailing Address - Country:US
Mailing Address - Phone:214-616-7318
Mailing Address - Fax:
Practice Address - Street 1:250 S 9TH ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-3919
Practice Address - Country:US
Practice Address - Phone:715-582-2247
Practice Address - Fax:920-983-5174
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4122-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant