Provider Demographics
NPI:1801331541
Name:MIRANDA CANNON PLLC
Entity type:Organization
Organization Name:MIRANDA CANNON PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-714-8606
Mailing Address - Street 1:504 BARNES BLVD BLDG 504
Mailing Address - Street 2:MCCHORD MAIN EXCHANGE OPTOMETRY CENTER
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98438-1304
Mailing Address - Country:US
Mailing Address - Phone:253-588-1741
Mailing Address - Fax:253-588-1731
Practice Address - Street 1:504 BARNES BLVD BLDG 504
Practice Address - Street 2:MCCHORD MAIN EXCHANGE OPTOMETRY CENTER
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98438-1304
Practice Address - Country:US
Practice Address - Phone:253-588-1741
Practice Address - Fax:253-588-1731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60160071152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty