Provider Demographics
NPI:1912458845
Name:LAZARO, BRYAN KEOKE (PMHNP)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEOKE
Last Name:LAZARO
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5223 1/2 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-8707
Mailing Address - Country:US
Mailing Address - Phone:602-888-3474
Mailing Address - Fax:
Practice Address - Street 1:3031 W NORTHERN AVE STE 109
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-6695
Practice Address - Country:US
Practice Address - Phone:602-888-3474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP9561363LP0808X
AZAP9561363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health