Healthcare Provider Details

I. General information

NPI: 1407162571
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E AMENDE DRIVE
ODESSA WA
99159-0000
US

IV. Provider business mailing address

122 W 7TH AVE
SPOKANE WA
99204-2349
US

V. Phone/Fax

Practice location:
  • Phone: 509-982-2614
  • Fax:
Mailing address:
  • Phone: 509-838-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease 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