Provider Demographics
NPI:1063611408
Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES WASHINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR 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:425-358-9786
Mailing Address - Street 1:PO BOX 31001-4110
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-4110
Mailing Address - Country:US
Mailing Address - Phone:425-525-6717
Mailing Address - Fax:425-525-6700
Practice Address - Street 1:420 GOLF CLUB RD SE
Practice Address - Street 2:SUITE 203
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1048
Practice Address - Country:US
Practice Address - Phone:360-493-7469
Practice Address - Fax:360-459-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAH-159261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8919875OtherL&I CRIME VICTIMS
WA129210OtherL&I
WA7115611Medicaid
WAG115117400Medicare PIN