MEDICARE: PROVIDENCE HEALTH & SERVICES - WASHINGTON

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	225000000X	Orthotic Fitter
2	208600000X	Surgery Physician	H-050	WA
3	207R00000X	Internal Medicine Physician	H-050	WA
4	225100000X	Physical Therapist
5	1041C0700X	Clinical Social Worker
6	207X00000X	Orthopaedic Surgery Physician	H-050	WA
7	207Q00000X	Family Medicine Physician	H-050	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	115284	OTHER	WA	L&I STATE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922259738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HEALTH & SERVICES - WASHINGTON

Provider Business Mailing Address
First Line	:	PO BOX 31001-4114
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91110-4114
Country	:	US
Telephone Number	:	509-529-8905
Fax Number	:	509-526-8402

Provider Business Practice Location Address
First Line	:	380 CHASE AVENUE
Second Line	:	PMG SE WA
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-2924
Country	:	US
Telephone Number	:	509-526-3333
Fax Number	:	509-526-8402

Authorized Official
Title or Position	:	ASSISTANT SECRETARY OF ENROLLMENTS
Name	:	DONALD W. ANDERSON JR.
Credential	:
Telephone Number	:	425-358-9786

Provider Enumeration Date	:	10/10/2008
Last Update Date	:	02/17/2026

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