Healthcare Provider Details

I. General information

NPI: 1518034180
Provider Name (Legal Business Name): N W PEDIATRIC CENTER INC P S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 COOKS HILL RD
CENTRALIA WA
98531-9073
US

IV. Provider business mailing address

1911 COOKS HILL RD
CENTRALIA WA
98531-9073
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-6778
  • Fax: 360-736-6552
Mailing address:
  • Phone: 360-736-6778
  • Fax: 360-736-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP30007039
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00028578
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP60086265
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00027525
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00038226
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD00039351
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00032554
License Number StateWA
# 8
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00043677
License Number StateWA
# 9
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP30006273
License Number StateWA
# 10
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00029916
License Number StateWA

VIII. Authorized Official

Name: LISA GAIL MCKAY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 360-736-6778