Healthcare Provider Details

I. General information

NPI: 1467859645
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 226TH PL SE SUITE 205
ISSAQUAH WA
98027-8969
US

IV. Provider business mailing address

805 MADISON ST SUITE 901
SEATTLE WA
98104-1172
US

V. Phone/Fax

Practice location:
  • Phone: 425-392-8611
  • Fax: 425-392-9012
Mailing address:
  • Phone: 206-264-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number601484763
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number601484763
License Number StateWA

VIII. Authorized Official

Name: MR. DAVID G. FITZGERALD
Title or Position: CEO
Credential:
Phone: 206-838-2599