NPIMap

Organization Active NPI

Providence Health & Services-Wa

  • Addiction Medicine (Family Medicine) Physician
  • Everett, WA
National Provider Identifier
1306097415
Registry record updated May 7, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Addiction Medicine (Family Medicine) PhysicianTaxonomy code 207QA0401X
Legal business name
PROVIDENCE HEALTH & SERVICES-WA
Practice address
916 Pacific Ave
1 South
Everett, WA 98201-4147
Phone
(425) 258-7390
Fax
(425) 258-7379
NPI assigned
Oct 7, 2008
Last updated
May 7, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 7, 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
Asst Secretary-Enrollment
Phone
(425) 358-9786

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X NU
Family Nurse Practitioner 363LF0000X NU
Psychiatric/Mental Health Nurse Practitioner 363LP0808X NU
Addiction Medicine (Family Medicine) Physician 207QA0401X NU Primary

Addresses

Primary practice location

916 Pacific Ave
1 South
Everett, WA 98201-4147

Mailing address

PO Box 31001-4110
Pasadena, CA 91110-4110

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090106000737 WA Part B Supplier - Clinic/Group Practice 0648330787 Receives reassigned benefits from 145 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Everett, WA

Other NPIs on the same Medicare enrollment 6

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

National Provider Directory

National Provider Directory
Tax ID family
Providence Health Service-9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

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

Locations

916 Pacific Ave
#1S
Everett, WA 98201
Phone (425) 258-7390

Practitioners & affiliated clinicians

Practitioners 9

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": "1223337600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746576000000",
    "number": "1306097415",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "916 PACIFIC AVE",
            "address_2": "1 SOUTH",
            "city": "EVERETT",
            "state": "WA",
            "postal_code": "982014147",
            "telephone_number": "425-258-7390",
            "fax_number": "425-258-7379"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES-WA",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-10-07",
        "last_updated": "2025-05-07",
        "certification_date": "2025-05-07",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "ASST SECRETARY-ENROLLMENT",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207QA0401X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Addiction Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Everett, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 7, 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.