NPIMap

Organization Active NPI

Providence Health & Services - Washington

  • Family Medicine Physician
  • Mukilteo, WA
National Provider Identifier
1124279237
Registry record updated May 12, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
PROVIDENCE HEALTH & SERVICES - WASHINGTON
Practice address
4112 Harbour Pointe Blvd SW
Suite 100
Mukilteo, WA 98275-5457
Phone
(425) 347-6330
Fax
(425) 347-6335
NPI assigned
Oct 7, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 12, 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 4

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

Addresses

Primary practice location

4112 Harbour Pointe Blvd SW
Suite 100
Mukilteo, WA 98275-5457

Mailing address

PO Box 31001-4114
Pasadena, CA 91110-4114
Phone (425) 358-9786

Other names 1

  • PMG NW WA - Harbour Pointe Doing business as

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

Other NPIs on the same Medicare enrollment 34

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

View all 34

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
50D0721425PMG NW Wa Harbour Pointe4112 Harbour Pointe Blvd SW, Mukilteo, WA 98275Provider-performed microscopyApr 4, 2028

National Provider Directory

National Provider Directory

Locations

1330 Rockefeller Ave
Ste 400
Everett, WA 98201
Phone (425) 261-4950

1717 13th St
Ste 401
Everett, WA 98201
Phone (425) 261-4910

Practitioners & affiliated clinicians

Practitioners 38

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

View all 38

NPI Registry JSON

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

{
    "created_epoch": "1223337600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747008000000",
    "number": "1124279237",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001-4114",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911104114",
            "telephone_number": "425-358-9786"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4112 HARBOUR POINTE BLVD SW",
            "address_2": "SUITE 100",
            "city": "MUKILTEO",
            "state": "WA",
            "postal_code": "982755457",
            "telephone_number": "425-347-6330",
            "fax_number": "425-347-6335"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - WASHINGTON",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-10-07",
        "last_updated": "2025-05-12",
        "certification_date": "2025-05-12",
        "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": true
        },
        {
            "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": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PMG NW WA - Harbour Pointe",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PMG NW WA - Harbour Pointe",
            "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 May 12, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.