Provider Demographics
NPI:1790936185
Name:PROVIDENCE HEALTH & SERVICES-WA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES-WA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST SECRETARY-ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 3369
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 PACIFIC AVE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4168
Practice Address - Country:US
Practice Address - Phone:425-258-7311
Practice Address - Fax:425-258-7618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-04
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133NN1002X, 363L00000X, 363LP0200X
WA261QD1600X
WAHAC.FS.00000084282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental DisabilitiesGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty