Healthcare Provider Details

I. General information

NPI: 1003050709
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - WA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 HARBOUR POINTE BLVD SW SUITE100
MUKILTEO WA
98275-5457
US

IV. Provider business mailing address

PO BOX 34439
SEATTLE WA
98124-1439
US

V. Phone/Fax

Practice location:
  • Phone: 425-347-6350
  • Fax: 425-347-6335
Mailing address:
  • Phone: 425-316-5469
  • Fax: 425-316-5484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
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