Basic Information
| Provider Information | |||||||||
| NPI: | 1326584673 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROLIANCE SURGEONS, INC., P.S. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHWEST WOMEN'S HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 MADISON ST STE 1150 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981043558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063863400 | ||||||||
| FaxNumber: | 2063863411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 MADISON ST STE 1150 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981043558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063863400 | ||||||||
| FaxNumber: | 2063863411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2017 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLEISLE | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF RISK OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2068382590 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 601484763 | WA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LW0102X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2074883 | 05 | WA | MEDICAID |