Healthcare Provider Details

I. General information

NPI: 1023236528
Provider Name (Legal Business Name): WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 HOYT AVE STE A
EVERETT WA
98203-2351
US

IV. Provider business mailing address

4225 HOYT AVE STE A
EVERETT WA
98203-2351
US

V. Phone/Fax

Practice location:
  • Phone: 425-259-3122
  • Fax: 425-252-9860
Mailing address:
  • Phone: 425-259-3122
  • Fax: 425-252-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number601474013
License Number StateWA

VIII. Authorized Official

Name: MS. VICKI MCGINNIS
Title or Position: HIPAA PRIVACY OFFICER
Credential:
Phone: 425-259-4041