Healthcare Provider Details

I. General information

NPI: 1134514433
Provider Name (Legal Business Name): PROLIANCE SURGEONS, INC., P.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3216 NE 45TH PL STE 304
SEATTLE WA
98105-4028
US

IV. Provider business mailing address

601 BROADWAY FL 6
SEATTLE WA
98122-5330
US

V. Phone/Fax

Practice location:
  • Phone: 206-386-2600
  • Fax: 206-622-1644
Mailing address:
  • Phone: 206-386-2600
  • Fax: 206-622-1644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number601484763
License Number StateWA

VIII. Authorized Official

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