Provider Demographics
NPI:1578983532
Name:DOCTOR CANNON PLLC
Entity Type:Organization
Organization Name:DOCTOR CANNON PLLC
Other - Org Name:CANNON EYECARE (AT MARKET OPTICAL)
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-714-8606
Mailing Address - Street 1:2602 NE UNIVERSITY VILLAGE ST
Mailing Address - Street 2:SUITE B (AT MARKET OPTICAL)
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-5023
Mailing Address - Country:US
Mailing Address - Phone:206-522-9323
Mailing Address - Fax:206-525-3841
Practice Address - Street 1:2602 NE UNIVERSITY VILLAGE ST
Practice Address - Street 2:SUITE B (AT MARKET OPTICAL)
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5023
Practice Address - Country:US
Practice Address - Phone:206-522-9323
Practice Address - Fax:206-525-3841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty