Provider Demographics
NPI:1043822372
Name:LEBO, BRYAN SCOTT (DNP, ARNP, FNP)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:SCOTT
Last Name:LEBO
Suffix:
Gender:M
Credentials:DNP, ARNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9425 N NEVADA ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1286
Mailing Address - Country:US
Mailing Address - Phone:509-270-0065
Mailing Address - Fax:509-319-2520
Practice Address - Street 1:9425 N NEVADA ST STE 300
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1286
Practice Address - Country:US
Practice Address - Phone:509-270-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X, 332B00000X
WAAP61091392363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP61091392Medicaid