Healthcare Provider Details

I. General information

NPI: 1659194215
Provider Name (Legal Business Name): SHANNON CHAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 E PINE ST
SEATTLE WA
98122-4021
US

IV. Provider business mailing address

1317 E PINE ST
SEATTLE WA
98122-4021
US

V. Phone/Fax

Practice location:
  • Phone: 206-420-8328
  • Fax: 206-466-5356
Mailing address:
  • Phone: 206-420-8328
  • Fax: 206-466-5356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD61651235
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: