Provider Demographics
NPI:1770764342
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: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 1:21911 76TH AVE W STE 211
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7918
Mailing Address - Country:US
Mailing Address - Phone:425-775-6651
Mailing Address - Fax:
Practice Address - Street 1:21911 76TH AVE W STE 211
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7918
Practice Address - Country:US
Practice Address - Phone:425-775-6651
Practice Address - Fax:425-670-6718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207YX0901X, 261QM1300X, 261QM1300X
WA601484763231H00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA227718OtherLABOR & INDUSTRIES
WA1060556Medicaid