Provider Demographics
NPI:1780376798
Name:ISSE, MOHAMEDDEQ A
Entity type:Individual
Prefix:
First Name:MOHAMEDDEQ
Middle Name:A
Last Name:ISSE
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 1:5939 S 23RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-4901
Mailing Address - Country:US
Mailing Address - Phone:414-553-3574
Mailing Address - Fax:
Practice Address - Street 1:5939 S 23RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-4901
Practice Address - Country:US
Practice Address - Phone:414-553-3574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WII200-5419-7001-07343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)