Healthcare Provider Details

I. General information

NPI: 1992411029
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 S 102ND ST STE 220
TUKWILA WA
98168-1869
US

IV. Provider business mailing address

PO BOX 94511
SEATTLE WA
98124-6811
US

V. Phone/Fax

Practice location:
  • Phone: 206-320-4000
  • Fax:
Mailing address:
  • Phone: 206-320-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

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