Healthcare Provider Details

I. General information

NPI: 1205307253
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 BOREN AVE STE 711
SEATTLE WA
98104-3301
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: 425-323-6868
Mailing address:
  • Phone: 425-823-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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