Provider Demographics
NPI:1598289274
Name:BRYAN, LUCAS ALEXANDER
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:ALEXANDER
Last Name:BRYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:IONA
Mailing Address - State:ID
Mailing Address - Zip Code:83427-0545
Mailing Address - Country:US
Mailing Address - Phone:208-529-3096
Mailing Address - Fax:
Practice Address - Street 1:1535 E TERRY ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-881-4385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer