Provider Demographics
NPI:1740727106
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 1:1101 MADISON ST STE 950
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3592
Mailing Address - Country:US
Mailing Address - Phone:206-682-5800
Mailing Address - Fax:
Practice Address - Street 1:1101 MADISON ST STE 950
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3592
Practice Address - Country:US
Practice Address - Phone:206-682-5800
Practice Address - Fax:206-233-9657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601484763207V00000X
207V00000X, 261QM1300X, 363LW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2075030Medicaid