1255736971 NPI number — PROLIANCE SURGEONS, INC., P.S.

Table of content: (NPI 1255736971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255736971 NPI number — PROLIANCE SURGEONS, INC., P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROLIANCE SURGEONS, INC., P.S.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROLIANCE PUYALLUP SURGEONS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255736971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1519 3RD ST SE STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98372-3742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-840-4994
Provider Business Mailing Address Fax Number:
253-770-1105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1519 3RD ST SE STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-3742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-840-4994
Provider Business Practice Location Address Fax Number:
253-770-1105
Provider Enumeration Date:
10/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PLEASANT
Authorized Official First Name:
CORI
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
MGR PROVIDER RELATIONS/ENROLLMENT
Authorized Official Telephone Number:
206-838-2585

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  601484763 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086X0206X , with the licence number: 601484763 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 601484763 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208C00000X , with the licence number: 601484763 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 338355 . This is a "WA LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0532700054 . This is a "DME" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2042632 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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