Healthcare Provider Details

I. General information

NPI: 1184351579
Provider Name (Legal Business Name): BRYAN RAZO FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1896 E BABBIT LN
SAN LUIS AZ
85336-7820
US

IV. Provider business mailing address

PO BOX 617
SOMERTON AZ
85350-0617
US

V. Phone/Fax

Practice location:
  • Phone: 928-722-6112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number226505
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number226505
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: