Provider Demographics
NPI:1841610169
Name:PROLIANCE SURGEONS, INC., P.S.
Entity Type:Organization
Organization Name:PROLIANCE SURGEONS, INC., P.S.
Other - Org Name:PLASTIC & RECONSTRUCTIVE SURGEONS
Other - Org Type:Doing Business As
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 1:17930 TALBOT RD S
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6230
Mailing Address - Country:US
Mailing Address - Phone:425-228-3187
Mailing Address - Fax:204-228-7972
Practice Address - Street 1:17930 TALBOT RD S
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6230
Practice Address - Country:US
Practice Address - Phone:425-228-3187
Practice Address - Fax:425-228-7972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601484763208200000X
208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2036917Medicaid
WA326119OtherWA L&I