Healthcare Provider Details

I. General information

NPI: 1912458845
Provider Name (Legal Business Name): BRYAN KEOKE LAZARO PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 E BASELINE RD STE F4
TEMPE AZ
85283-1519
US

IV. Provider business mailing address

5223 1/2 S 5TH ST
PHOENIX AZ
85040-8707
US

V. Phone/Fax

Practice location:
  • Phone: 602-888-3474
  • Fax: 762-212-4347
Mailing address:
  • Phone: 602-888-3474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP9561
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: