Healthcare Provider Details

I. General information

NPI: 1790590974
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP WASHINGTON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 E D ST
DEER PARK WA
99006-5167
US

IV. Provider business mailing address

55 W TIETAN ST
WALLA WALLA WA
99362-4445
US

V. Phone/Fax

Practice location:
  • Phone: 509-276-5005
  • Fax: 509-276-7785
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EDWARD FARGIS
Title or Position: GENERAL COUNSEL
Credential:
Phone: 571-366-8850