Healthcare Provider Details

I. General information

NPI: 1457940660
Provider Name (Legal Business Name): MAKAILA SAMONNE-HUNT PALAZO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 JAY ST
FOSSIL OR
97830-8371
US

IV. Provider business mailing address

712 JAY ST PO BOX 307
FOSSIL OR
97830-8371
US

V. Phone/Fax

Practice location:
  • Phone: 541-763-2725
  • Fax:
Mailing address:
  • Phone: 541-763-2725
  • Fax: 833-601-2016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA202991
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: