NPIMap

Organization Active NPI

Providence Health & Services - Washington

Doing business as PMG SE WA - Lab

  • Clinical Medical Laboratory
  • Walla Walla, WA
National Provider Identifier
1316433527
Registry record updated May 6, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Medical LaboratoryTaxonomy code 291U00000X
License
MTSC.FS.60877120 Issued in WA
Legal business name
PROVIDENCE HEALTH & SERVICES - WASHINGTON
Doing business as
PMG SE WA - Lab
Practice address
1025 S 2ND Ave
Walla Walla, WA 99362-4116
Phone
(509) 897-5174
NPI assigned
Jul 11, 2018
Last updated
May 6, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 6, 2025

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

Authorized official

Name
Mr. Donald Wayne Anderson Jr.
Title
Asst Secretary-Enrollment/Admin Dir
Phone
(425) 358-9786

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Medical Laboratory 291U00000X MTSC.FS.60877120 WA Primary

Addresses

Primary practice location

1025 S 2ND Ave
Walla Walla, WA 99362-4116

Mailing address

PO Box 32
Liberty Lake, WA 99019-0032

Other names 1

  • PMG SE WA - Lab Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20081223000478 WA Part B Supplier - Clinic/Group Practice 2860552973 Receives reassigned benefits from 295 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

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

Locations

1017 S 2nd Ave
Ste 4
Walla Walla, WA 99362
Phone (509) 529-4850

Practitioners & affiliated clinicians

Practitioners 11

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": "1531267200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746489600000",
    "number": "1316433527",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 32",
            "city": "LIBERTY LAKE",
            "state": "WA",
            "postal_code": "990190032"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1025 S 2ND AVE",
            "city": "WALLA WALLA",
            "state": "WA",
            "postal_code": "993624116",
            "telephone_number": "509-897-5174"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES - WASHINGTON",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-11",
        "last_updated": "2025-05-06",
        "certification_date": "2025-05-06",
        "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/ADMIN DIR",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "WA",
            "license": "MTSC.FS.60877120",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PMG SE WA - Lab",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PMG SE WA - Lab",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Walla Walla, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 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.