MEDICARE: DOCTOR CANNON PLLC

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		WA

General Provider Information

NPI Number	:	1578983532
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOCTOR CANNON PLLC

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	:	MEMBER
Name	:	DR. MIRANDA CANNON
Credential	:	O.D.
Telephone Number	:	206-714-8606

Provider Enumeration Date	:	04/17/2014
Last Update Date	:	09/20/2022

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