Healthcare Provider Details

I. General information

NPI: 1598289274
Provider Name (Legal Business Name): LUCAS ALEXANDER BRYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10189 N 4800 W
HIGHLAND UT
84003-8828
US

IV. Provider business mailing address

642 E 60 S
AMERICAN FORK UT
84003-2862
US

V. Phone/Fax

Practice location:
  • Phone: 801-610-8810
  • Fax:
Mailing address:
  • Phone: 208-529-3096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: