NPIMap

Organization Active NPI

Providence Health & Services - Wa

  • General Practice Physician
  • Mukilteo, WA
National Provider Identifier
1003050709
Registry record updated Jul 25, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
Legal business name
PROVIDENCE HEALTH & SERVICES - WA
Practice address
4112 Harbour Pointe Blvd SW
Suite100
Mukilteo, WA 98275-5457
Phone
(425) 347-6350
Fax
(425) 347-6335
NPI assigned
Apr 24, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 25, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Donald Wayne Anderson Jr.
Title
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
General Practice PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208D00000X Primary
Durable Medical Equipment & Medical Supplies 332B00000X

Addresses

Primary practice location

4112 Harbour Pointe Blvd SW
Suite100
Mukilteo, WA 98275-5457

Mailing address

PO Box 34439
Seattle, WA 98124-1439
Phone (425) 316-5469

Other names 1

  • PMG NW WA H P Urgent Care Doing business as

Other NPIs on the same Medicare enrollment 34

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 34

Practitioners 38

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 38

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20081224000111 WA Part B Supplier - Clinic/Group Practice 8325100480 Receives reassigned benefits from 816 practitioners
34 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

National Provider Directory

National Provider Directory

Locations

44 Leigh St
Clinton, NJ 08809

180 Fort Washington Ave
#236
New York, NY 10032
Phone (212) 305-2330

2205 Broadway
Everett, WA 98201
Phone (425) 252-5213

13110 Bothell Everett Hwy
#A
Everett, WA 98208

1321 Colby Ave
#A
Everett, WA 98201

12800 Bothell Everett Hwy
Ste 11
Everett, WA 98208

916 Pacific Ave
Fl 2
Everett, WA 98201
Phone (425) 261-4910

2205 Broadway
#A
Everett, WA 98201

1330 Rockefeller Ave
Ste 210
Everett, WA 98201
Phone (425) 261-4940

12800 Bothell Everett Hwy
#260B
Everett, WA 98208

3216 Norton Ave
Ste 201
Everett, WA 98201
Phone (425) 258-4624

1330 Rockefeller Ave
Ste 120
Everett, WA 98201
Phone (425) 339-5424

916 Pacific Ave
#7
Everett, WA 98201

12800 Bothell Everett Hwy
Ste 1
Everett, WA 98208

12333 NE 130th Ln
Ste 310
Kirkland, WA 98034
Phone (425) 899-6700

12333 NE 130th Ln
Ste 130
Kirkland, WA 98034

11630 State Ave Ste G
Marysville, WA 98271

11603 State Ave
Marysville, WA 98271

4112 Harbour Pointe Blvd SW
Mukilteo, WA 98275
Phone (425) 347-6330

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1240531200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1753401600000",
    "number": "1003050709",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 34439",
            "city": "SEATTLE",
            "state": "WA",
            "postal_code": "981241439",
            "telephone_number": "425-316-5469",
            "fax_number": "425-316-5484"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4112 HARBOUR POINTE BLVD SW",
            "address_2": "SUITE100",
            "city": "MUKILTEO",
            "state": "WA",
            "postal_code": "982755457",
            "telephone_number": "425-347-6350",
            "fax_number": "425-347-6335"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - WA",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-04-24",
        "last_updated": "2025-07-25",
        "certification_date": "2025-07-25",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY OF ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PMG NW WA H P Urgent Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mukilteo, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.