Healthcare Provider Details

I. General information

NPI: 1770764342
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2007
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21911 76TH AVE W STE 211
EDMONDS WA
98026-7918
US

IV. Provider business mailing address

21911 76TH AVE W STE 211
EDMONDS WA
98026-7918
US

V. Phone/Fax

Practice location:
  • Phone: 425-775-6651
  • Fax: 425-670-6718
Mailing address:
  • Phone: 425-775-6651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number601484763
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number601484763
License Number StateWA

VIII. Authorized Official

Name: CORI M. PLEASANT
Title or Position: MGR PROVIDER RELATIONS/ENROLLMENT
Credential:
Phone: 206-838-2585