Provider Demographics
NPI:1700168085
Name:MBAKAYA-CHEN, PRAXIDES MUKOCHE (ARNP)
Entity Type:Individual
Prefix:
First Name:PRAXIDES
Middle Name:MUKOCHE
Last Name:MBAKAYA-CHEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5548 SADDLEBACK CT
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-6015
Mailing Address - Country:US
Mailing Address - Phone:908-644-8361
Mailing Address - Fax:352-360-6582
Practice Address - Street 1:2020 TALLEY RD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3426
Practice Address - Country:US
Practice Address - Phone:352-315-7800
Practice Address - Fax:352-360-6582
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9323763363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FK403ZOtherMEDICARE PTAN
FL004023800Medicaid