Provider Demographics
NPI:1720225592
Name:MCCANN, MIKE (LMP)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:MCCANN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 ARCH PL SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-2032
Mailing Address - Country:US
Mailing Address - Phone:206-683-1175
Mailing Address - Fax:
Practice Address - Street 1:9250 45TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-2633
Practice Address - Country:US
Practice Address - Phone:206-937-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist