1427356211 NPI number — PROLIANCE SURGEONS, INC., P.S.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427356211 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:
Provider Other Organization Name Type Code:
6
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:
1427356211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 S LAVENTURE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98274-6033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-424-7041
Provider Business Mailing Address Fax Number:
360-424-2418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2720 COMMERCIAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANACORTES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98221-2734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-424-7041
Provider Business Practice Location Address Fax Number:
360-424-2418
Provider Enumeration Date:
03/03/2011

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: 207X00000X , 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: 208100000X , 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: 225100000X , 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: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1042545 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 121724 . This is a "WA LABOR & INDUSTRIES" identifier . This identifiers is of the category "OTHER".




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