Provider Demographics
NPI:1255893301
Name:SURPRISE, TAYLOR MAKANA (PA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MAKANA
Last Name:SURPRISE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 MAA ST
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-3603
Mailing Address - Country:US
Mailing Address - Phone:808-446-7120
Mailing Address - Fax:808-446-7121
Practice Address - Street 1:165 MAA ST
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-3603
Practice Address - Country:US
Practice Address - Phone:808-446-7120
Practice Address - Fax:808-446-7121
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-1054363A00000X
AZ7564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty