Healthcare Provider Details

I. General information

NPI: 1154672947
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 CHASE AVENUE PMG SE WA RURAL HEALTH CLINIC
WALLA WALLA WA
99362-2924
US

IV. Provider business mailing address

PO BOX 34439 PMG SE WA RURAL HEALTH CLINIC
SEATTLE WA
98124-1439
US

V. Phone/Fax

Practice location:
  • Phone: 509-526-3333
  • Fax: 509-526-8402
Mailing address:
  • Phone: 509-526-3333
  • Fax: 509-526-8402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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 Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786