Provider Demographics
NPI:1659871622
Name:PROLIANCE SURGEONS, INC., P.S
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS, INC., P.S
Other - Org Name:PROLIANCE SURGEONS ANKLE AND FOOT OF EDMONDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR PROVIDER RELATIONS/ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:CORI
Authorized Official - Middle Name:M
Authorized Official - Last Name:PLEASANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-838-2585
Mailing Address - Street 1:7320 216TH ST SW STE 320
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8006
Mailing Address - Country:US
Mailing Address - Phone:425-673-3900
Mailing Address - Fax:
Practice Address - Street 1:7320 216TH ST SW STE 320B
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8006
Practice Address - Country:US
Practice Address - Phone:425-775-6996
Practice Address - Fax:425-670-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-16
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213E00000X, 213ES0103X
WA601484763213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA49391OtherWA LABOR & INDUSTRIES
WA1043983Medicaid
WA0532700039OtherNSC DME