Healthcare Provider Details

I. General information

NPI: 1760886980
Provider Name (Legal Business Name): WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 AVENUE D
SNOHOMISH WA
98290-2330
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 360-568-1554
  • Fax: 360-568-1722
Mailing address:
  • Phone: 425-259-4041
  • Fax: 425-252-6642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: VICKI MCGINNIS
Title or Position: PRIVACY OFFICER
Credential:
Phone: 425-259-4041