Provider Demographics
NPI:1811936990
Name:PROLIANCE SURGEONS, INC., P.S.
Entity type:Organization
Organization Name:PROLIANCE SURGEONS, INC., P.S.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF RISK OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-838-2590
Mailing Address - Street 1:900 TERRY AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-4232
Mailing Address - Country:US
Mailing Address - Phone:206-382-1021
Mailing Address - Fax:206-382-1026
Practice Address - Street 1:900 TERRY AVE FL 3
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-4232
Practice Address - Country:US
Practice Address - Phone:206-382-1021
Practice Address - Fax:206-382-9369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601484763261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1045762Medicaid
WA208954OtherWA L&I