Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1922 E CESAR CHAVEZ BLVD SUITE 7
SAN LUIS AZ
85336
US

IV. Provider business mailing address

PO BOX 8691
SAN LUIS AZ
85349-6832
US

V. Phone/Fax

Practice location:
  • Phone: 928-750-4006
  • Fax:
Mailing address:
  • Phone: 928-750-4006
  • Fax: 928-276-4730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number226505
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number226505
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: