Healthcare Provider Details

I. General information

NPI: 1588360176
Provider Name (Legal Business Name): MAKENA SUZANNE FOWLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 S BOND AVE
PORTLAND OR
97239-4501
US

IV. Provider business mailing address

1400 SW 5TH AVE STE 500
PORTLAND OR
97201-5537
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-4314
  • Fax: 503-346-6810
Mailing address:
  • Phone: 866-617-6855
  • Fax: 503-346-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA214820
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: