Healthcare Provider Details

I. General information

NPI: 1265683650
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES-WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2008
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19200 N KELSEY ST
MONROE WA
98272-1431
US

IV. Provider business mailing address

PO BOX 31001-4114
PASADENA CA
91110-4114
US

V. Phone/Fax

Practice location:
  • Phone: 360-794-7994
  • Fax: 360-805-4757
Mailing address:
  • Phone: 253-589-7864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786