MEDICARE: DR. MIRANDA MURRAY CANNON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	60160071	WA

General Provider Information

NPI Number	:	1104130871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIRANDA MURRAY CANNON O.D.

Provider Business Mailing Address
First Line	:	2602 NE UNIVERSITY VILLAGE ST
Second Line	:	SUITE B (AT MARKET OPTICAL)
City	:	SEATTLE
State	:	WA
Zip	:	98105-5023
Country	:	US
Telephone Number	:	206-522-9323
Fax Number	:	206-525-3841

Provider Business Practice Location Address
First Line	:	2602 NE UNIVERSITY VILLAGE ST
Second Line	:	SUITE B (AT MARKET OPTICAL)
City	:	SEATTLE
State	:	WA
Zip	:	98105-5023
Country	:	US
Telephone Number	:	206-522-9323
Fax Number	:	206-525-3841

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2010
Last Update Date	:	01/12/2016

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