Healthcare Provider Details

I. General information

NPI: 1417499575
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3216 NORTON AVE STE 101
EVERETT WA
98201-4290
US

IV. Provider business mailing address

7320 216TH ST SW STE 320
EDMONDS WA
98026-8006
US

V. Phone/Fax

Practice location:
  • Phone: 425-252-4700
  • Fax: 425-252-4788
Mailing address:
  • Phone: 425-673-3900
  • Fax: 425-252-4788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation 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