# EVERGREEN CHILDREN'S CLINIC, PLLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Other names:** Pediatrics PM
- **Organization subpart:** No

## Provider details

- **NPI number:** 1568527539
- **Authorized official:** MRS. SUSANNE I ROACH (OFFICE MANAGER)
- **Authorized official phone:** (253) 848-2303

## Contact information

- **Practice address:** 1910 S MERIDIAN, SUITE A, PUYALLUP, WA 98371-7531
- **Practice address phone:** (253) 848-2303
- **Practice address fax:** (253) 848-8956
- **Mailing address:** 1910 S MERIDIAN, SUITE A, PUYALLUP, WA 98371-7531
- **Mailing address phone:** (253) 848-2303
- **Mailing address fax:** (253) 848-8956

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | NULL | Yes |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 12/27/2006
- **Last updated:** 08/22/2020