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 1:2111 E BASELINE RD STE F4
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1519
Practice Address - Country:US
Practice Address - Phone:602-888-3474
Practice Address - Fax:762-212-4347
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP9561363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health