Provider Demographics
NPI:1659194215
Name:CHAN, SHANNON (OD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15808 MILL CREEK BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1500
Mailing Address - Country:US
Mailing Address - Phone:425-745-5650
Mailing Address - Fax:425-337-1342
Practice Address - Street 1:15808 MILL CREEK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1500
Practice Address - Country:US
Practice Address - Phone:425-745-5650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61651235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist