Provider Demographics
NPI:1952525636
Name:NORTHWEST SPOKANE PEDIATRICS, PLLC
Entity type:Organization
Organization Name:NORTHWEST SPOKANE PEDIATRICS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:509-866-4646
Mailing Address - Street 1:220 E ROWAN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-2244
Mailing Address - Country:US
Mailing Address - Phone:509-483-4060
Mailing Address - Fax:509-483-0043
Practice Address - Street 1:220 E ROWAN AVE STE 150
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-2244
Practice Address - Country:US
Practice Address - Phone:509-483-4060
Practice Address - Fax:509-483-0043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X, 261QM1300X, 363LP0200X
WA602279511261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1302215Medicaid
WA1302215Medicaid