Provider Demographics
NPI:1558919449
Name:LEE, SHANNON EUNHWA
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:EUNHWA
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3046 KNIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-2815
Mailing Address - Country:US
Mailing Address - Phone:215-639-4500
Mailing Address - Fax:215-604-0355
Practice Address - Street 1:3046 KNIGHTS RD
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-2815
Practice Address - Country:US
Practice Address - Phone:215-639-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003615152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103683890-0002Medicaid
PA103683890-0001Medicaid