Provider Demographics
NPI:1235944414
Name:PRIVIA MEDICAL GROUP WASHINGTON, PLLC
Entity type:Organization
Organization Name:PRIVIA MEDICAL GROUP WASHINGTON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FARGIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-366-8850
Mailing Address - Street 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 S PARK ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006-7025
Practice Address - Country:US
Practice Address - Phone:509-262-9000
Practice Address - Fax:509-276-3034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health