Healthcare Provider Details

I. General information

NPI: 1760393052
Provider Name (Legal Business Name): EVERGREEN DIAGNOSTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 UNION AVE SE STE 200
OLYMPIA WA
98501
US

IV. Provider business mailing address

400 UNION AVE SE STE 200
OLYMPIA WA
98501
US

V. Phone/Fax

Practice location:
  • Phone: 360-615-3142
  • Fax: 360-515-9312
Mailing address:
  • Phone: 360-615-3142
  • Fax: 360-515-9312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246X00000X
TaxonomyCardiovascular Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA S WALKER
Title or Position: OPERATIONS ADMINISTRATOR
Credential: ARDMS, RVT, RDCS
Phone: 360-615-3142