Provider Demographics
NPI:1346234275
Name:BUCKMASTER, SHANNON MARIE (OD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:BUCKMASTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BUCKMASTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5794 S AMBER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-1948
Mailing Address - Country:US
Mailing Address - Phone:503-329-1696
Mailing Address - Fax:503-925-9733
Practice Address - Street 1:1495 S BLACK RIDGE DR STE A270
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-7174
Practice Address - Country:US
Practice Address - Phone:503-329-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3055AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U24849Medicare UPIN
U24849Medicare UPIN