Provider Demographics
NPI:1396221230
Name:SANDERS, SHANE RYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:RYAN
Last Name:SANDERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 S VIRGINIA ST UNIT 11
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4469
Mailing Address - Country:US
Mailing Address - Phone:928-308-0275
Mailing Address - Fax:
Practice Address - Street 1:3192 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-6610
Practice Address - Country:US
Practice Address - Phone:928-445-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002281152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist