Healthcare Provider Details

I. General information

NPI: 1669411617
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12911 120TH AVE NE STE H210
KIRKLAND WA
98034-3065
US

IV. Provider business mailing address

12911 120TH AVE NE STE G10
KIRKLAND WA
98034-3048
US

V. Phone/Fax

Practice location:
  • Phone: 425-823-4000
  • Fax: 425-821-3550
Mailing address:
  • Phone: 206-823-4000
  • Fax: 206-821-3550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery 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