Basic Information
Provider Information | |||||||||
NPI: | 1720280175 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FARMAKIS | ||||||||
FirstName: | SHANNON | ||||||||
MiddleName: | GRACE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEHNER | ||||||||
OtherFirstName: | SHANNON | ||||||||
OtherMiddleName: | GRACE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 19020 33RD AVE W STE 210 | ||||||||
Address2: |   | ||||||||
City: | LYNNWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 980364748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4255631500 | ||||||||
FaxNumber: | 4255631374 | ||||||||
Practice Location | |||||||||
Address1: | 19020 33RD AVE W STE 210 | ||||||||
Address2: |   | ||||||||
City: | LYNNWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 980364748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4255631500 | ||||||||
FaxNumber: | 4255631501 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2007 | ||||||||
LastUpdateDate: | 11/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 07/17/2007 | ||||||||
NPIReactivationDate: | 02/28/2008 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | M-14782 | ID | N |   | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | M-14782 | ID | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | MD60962082 | WA | N |   | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | 200813456 | MO | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 1720280175 | 05 | ID |   | MEDICAID | 2140822 | 05 | WA |   | MEDICAID |