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General NPI Number Information
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NPI Number | 1306097415
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Entity Type | Organization
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Legal Business Name | PROVIDENCE HEALTH & SERVICES-WA
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Dates
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Enumeration Date | 10/07/2008
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Last Update Date | 05/07/2025
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Provider Practice Location Address
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Address Line | 916 PACIFIC AVE 1 SOUTH
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City | EVERETT
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State | WA
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Zip | 98201-4147
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Country | US
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Telephone | 425-258-7390
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Fax | 425-258-7379
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Provider Business Mailing Address
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Address Line | PO BOX 31001-4110
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City | PASADENA
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State | CA
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Zip | 91110-4110
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ASST SECRETARY-ENROLLMENT
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Name | DONALD WAYNE ANDERSON JR.
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Credential |
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Telephone | 425-358-9786
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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