Healthcare Provider Details

I. General information

NPI: 1326564790
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6808 220TH ST SW STE 200
MOUNTLAKE TERRACE WA
98043-2187
US

IV. Provider business mailing address

805 MADISON ST STE 901
SEATTLE WA
98104-1172
US

V. Phone/Fax

Practice location:
  • Phone: 425-967-6480
  • Fax: 425-967-6485
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number601484763
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number601484763
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number601484763
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number601484763
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number601484763
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number601484763
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number601484763
License Number StateWA
# 8
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA KLEISLE
Title or Position: CHIEF RISK OFFICER
Credential:
Phone: 206-838-2590