Provider Demographics
NPI:1770015588
Name:HARBISON, SHAUNA CHRISTINE (OD)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:CHRISTINE
Last Name:HARBISON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 NE VILLAGE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-3825
Mailing Address - Country:US
Mailing Address - Phone:977-244-8734
Mailing Address - Fax:
Practice Address - Street 1:9730 SW WASHINGTON SQUARE RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-4453
Practice Address - Country:US
Practice Address - Phone:503-624-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2019-12-18
Deactivation Date:2019-12-11
Deactivation Code:
Reactivation Date:2019-12-18
Provider Licenses
StateLicense IDTaxonomies
OR2948AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist