Basic Information
| Provider Information | |||||||||
| NPI: | 1982774097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN WASHINGTON ONCOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4525 3RD AVE SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985031010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607543934 | ||||||||
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| Practice Location | |||||||||
| Address1: | 954 ANDERSON DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ABERDEEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985201001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605336906 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | EDGINGTON | ||||||||
| AuthorizedOfficialFirstName: | MELODY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3607543934 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 7086648 | 05 | WA | MEDICAID |