NPIMap

Organization Active NPI

Providence Health & Services Washington

  • Diagnostic Radiology Physician
  • Lacey, WA
National Provider Identifier
1003367863
Registry record updated May 13, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
PROVIDENCE HEALTH & SERVICES WASHINGTON
Practice address
4800 College St SE Ste E
Lacey, WA 98503-4389
Phone
(360) 489-2960
Fax
(360) 489-2961
NPI assigned
Oct 17, 2016
Last updated
May 13, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 13, 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 for Enrollment
Phone
(425) 358-9786

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2085R0202X Primary

Addresses

Primary practice location

4800 College St SE Ste E
Lacey, WA 98503-4389

Mailing address

PO Box 31001-4110
Pasadena, CA 91110-4110
Phone (360) 489-2960

Other names 1

  • Providence St Peter Hospital Diagnostic Imaging Lacey Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170223001678 WA Part B Supplier - Independent Diagnostic Testing Facility (Idtf) 7719873496 Practice locations: Lacey, WA

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Providence Health Serv Wa10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Locations

4800 College St SE
Ste E
Lacey, WA 98503
Phone (360) 486-2960

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1476662400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747094400000",
    "number": "1003367863",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001-4110",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911104110",
            "telephone_number": "360-489-2960"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4800 COLLEGE ST SE STE E",
            "city": "LACEY",
            "state": "WA",
            "postal_code": "985034389",
            "telephone_number": "360-489-2960",
            "fax_number": "360-489-2961"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES WASHINGTON",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-10-17",
        "last_updated": "2025-05-13",
        "certification_date": "2025-05-13",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY FOR ENROLLMENT",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence St Peter Hospital Diagnostic Imaging Lacey",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Lacey, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 13, 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.