MEDICARE: N W PEDIATRIC CENTER INC P S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	AP30006273	WA
2	133V00000X	Registered Dietitian	D160180464	WA
3	208000000X	Pediatrics Physician	MD00048049	WA
4	2084P0804X	Child & Adolescent Psychiatry Physician	MD00039351	WA
5	208000000X	Pediatrics Physician	MD00032554	WA
6	363LP0200X	Pediatric Nurse Practitioner	AP60093357	WA
7	208000000X	Pediatrics Physician	MD00028578	WA
8	363LP0200X	Pediatric Nurse Practitioner	AP60086265	WA
9	208000000X	Pediatrics Physician	MD00029916	WA
10	363LP0200X	Pediatric Nurse Practitioner	AP30007039	WA
11	363LP0200X	Pediatric Nurse Practitioner	AP30004257	WA
12	208000000X	Pediatrics Physician	MD00043677	WA
13	208000000X	Pediatrics Physician	MD00038226	WA
14	208000000X	Pediatrics Physician	MD00027525	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
13	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
14	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194091637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	N W PEDIATRIC CENTER INC P S

Provider Business Mailing Address
First Line	:	1911 COOKS HILL RD
Second Line	:
City	:	CENTRALIA
State	:	WA
Zip	:	98531-9073
Country	:	US
Telephone Number	:	360-736-6778
Fax Number	:	360-736-6552

Provider Business Practice Location Address
First Line	:	18313 PAULSON ST SW
Second Line	:
City	:	ROCHESTER
State	:	WA
Zip	:	98579-9262
Country	:	US
Telephone Number	:	360-736-6778
Fax Number	:	360-736-6552

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	LISA GAIL MCKAY
Credential	:
Telephone Number	:	360-736-6777

Provider Enumeration Date	:	03/29/2012
Last Update Date	:	10/09/2025

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