Healthcare Provider Details

I. General information

NPI: 1902166341
Provider Name (Legal Business Name): LUCAS M BRYANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2012
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S MOUNT JULIET RD STE 120
MT JULIET TN
37122-3968
US

IV. Provider business mailing address

660 S MOUNT JULIET RD STE 120
MT JULIET TN
37122-3968
US

V. Phone/Fax

Practice location:
  • Phone: 615-656-7859
  • Fax:
Mailing address:
  • Phone: 615-656-7859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number287468
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number57875
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: