=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407594138
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KNIGHT VISION NORTHWEST PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2022
-----------------------------------------------------
Last Update Date | 05/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 CEDAR AVE STE B1
-----------------------------------------------------
City | MARYSVILLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98270-4561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-760-1446
-----------------------------------------------------
Fax | 425-382-2146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 CEDAR AVE STE B1
-----------------------------------------------------
City | MARYSVILLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98270-4561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-760-1446
-----------------------------------------------------
Fax | 425-382-2146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PATRICK DEWAYNE KNIGHTON JR.
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 425-405-0837
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------