Healthcare Provider Details

I. General information

NPI: 1093933491
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: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 HOYT AVE STE C
EVERETT WA
98203-2351
US

IV. Provider business mailing address

1728 W MARINE VIEW DR STE 110
EVERETT WA
98201-2094
US

V. Phone/Fax

Practice location:
  • Phone: 425-252-8375
  • Fax: 425-252-8364
Mailing address:
  • Phone: 425-259-4041
  • Fax: 425-252-6642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number601474013
License Number StateWA

VIII. Authorized Official

Name: AMELIA EDENS
Title or Position: DIRECTOR OF PATIENT FINANCIAL SVCS
Credential:
Phone: 425-740-4142