Healthcare Provider Details

I. General information

NPI: 1417175811
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: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12728 19TH AVE SE STE 300
EVERETT WA
98208-6676
US

IV. Provider business mailing address

12728 19TH AVE SE STE 300
EVERETT WA
98208-6676
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-6801
  • Fax: 425-258-1944
Mailing address:
  • Phone: 425-252-1116
  • Fax: 425-252-1118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number601474013
License Number StateWA

VIII. Authorized Official

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