Basic Information
Provider Information | |||||||||
NPI: | 1952399123 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROLIANCE RAINIER ORTHOPEDIC INSTITUTE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3801 5TH ST SE STE 110 | ||||||||
Address2: |   | ||||||||
City: | PUYALLUP | ||||||||
State: | WA | ||||||||
PostalCode: | 983742106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538459585 | ||||||||
FaxNumber: | 2538481126 | ||||||||
Practice Location | |||||||||
Address1: | 3801 5TH ST SE STE 110 | ||||||||
Address2: |   | ||||||||
City: | PUYALLUP | ||||||||
State: | WA | ||||||||
PostalCode: | 983742106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538459585 | ||||||||
FaxNumber: | 2534354785 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2005 | ||||||||
LastUpdateDate: | 08/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PLEASANT | ||||||||
AuthorizedOfficialFirstName: | CORI | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | MGR PROVIDER RELATIONS/ENROLLMENT | ||||||||
AuthorizedOfficialTelephone: | 2068382585 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 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 | 0532700022 | 01 | WA | DME | OTHER | 1046356 | 05 | WA |   | MEDICAID | 218643 | 01 | WA | WA L&I | OTHER |