Provider Demographics
NPI:1235636853
Name:LYTLE, JUSTIN S (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:S
Last Name:LYTLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 SE BISHOP BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5537
Mailing Address - Country:US
Mailing Address - Phone:509-332-2517
Mailing Address - Fax:
Practice Address - Street 1:825 SE BISHOP BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5537
Practice Address - Country:US
Practice Address - Phone:509-332-2517
Practice Address - Fax:509-334-9247
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAOL60867716207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program