Provider Demographics
NPI:1285894147
Name:SHAKOOR-LUQMAN, WALI KHATEEB I (RN)
Entity type:Individual
Prefix:MR
First Name:WALI
Middle Name:KHATEEB
Last Name:SHAKOOR-LUQMAN
Suffix:I
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4572
Mailing Address - Country:US
Mailing Address - Phone:262-632-1113
Mailing Address - Fax:262-632-1113
Practice Address - Street 1:1513 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4572
Practice Address - Country:US
Practice Address - Phone:262-632-1113
Practice Address - Fax:262-632-1113
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI145431-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38252200Medicaid