NPIMap

Organization Active NPI

Providence Health & Services- Washington

Doing business as PMG NW WA Mill Creek Commons

  • Family Medicine Physician
  • Mill Creek, WA
National Provider Identifier
1790014504
Registry record updated May 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
PROVIDENCE HEALTH & SERVICES- WASHINGTON
Doing business as
PMG NW WA Mill Creek Commons
Practice address
16708 Bothell-Everett Highway
Suite 201
Mill Creek, WA 98012-6345
Phone
(425) 482-9020
Fax
(425) 482-9021
NPI assigned
Dec 8, 2009
Last updated
May 9, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 9, 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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

16708 Bothell-Everett Highway
Suite 201
Mill Creek, WA 98012-6345

Mailing address

PO Box 3360
Portland, OR 97208-3360
Phone (866) 399-2983

Other names 1

  • PMG NW WA Mill Creek Commons 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
50D2016034PMG NW Wa Mill Creek Commons16708 Bothell Everett Hwy Ste 201, Mill Creek, WA 98012Certificate of waiverApr 4, 2028

National Provider Directory

National Provider Directory
Tax ID family
PMG NW Wa Cardiology13 organizations share this tax ID, including this one

Other organizations with this tax ID 12

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

Practitioners & affiliated clinicians

Practitioners 30

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.

View all 30

NPI Registry JSON

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

{
    "created_epoch": "1260230400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746748800000",
    "number": "1790014504",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3360",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083360",
            "telephone_number": "866-399-2983"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16708 BOTHELL-EVERETT HIGHWAY",
            "address_2": "SUITE 201",
            "city": "MILL CREEK",
            "state": "WA",
            "postal_code": "980126345",
            "telephone_number": "425-482-9020",
            "fax_number": "425-482-9021"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTH & SERVICES- WASHINGTON",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-12-08",
        "last_updated": "2025-05-09",
        "certification_date": "2025-05-09",
        "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": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PMG NW WA Mill Creek Commons",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PMG NW WA Mill Creek Commons",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mill Creek, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 9, 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.