Healthcare Provider Details

I. General information

NPI: 1457133977
Provider Name (Legal Business Name): LOGAN MAKAYLA HAWKER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LOGAN DAVILA

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 S VISTA AVE
BOISE ID
83705-3453
US

IV. Provider business mailing address

1066 S SILVERSTONE WAY APT C230
MERIDIAN ID
83642-1365
US

V. Phone/Fax

Practice location:
  • Phone: 503-554-2521
  • Fax:
Mailing address:
  • Phone: 541-212-3842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: