Basic Information
| Provider Information | |||||||||
| NPI: | 1750320701 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
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| OtherOrganizationName: | PROLIANCE SURGEONS EVERETT BONE AND JOINT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 PACIFIC AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253392433 | ||||||||
| FaxNumber: | 4253398273 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 PACIFIC AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253392433 | ||||||||
| FaxNumber: | 4253398273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | PLEASANT | ||||||||
| AuthorizedOfficialFirstName: | CORI | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | MGR PROVIDER RELATIONS/ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 2068382585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0117X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2471M1202X | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Magnetic Resonance Imaging | 261QM1200X | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 123308 | 01 | WA | WA LABOR & INDUSTRIES | OTHER | 2012655 | 05 | WA | MEDICAID |