Healthcare Provider Details

I. General information

NPI: 1235507898
Provider Name (Legal Business Name): BRIAN LANCASTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 09/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

11801 226TH AVENUE CT E
BONNEY LAKE WA
98391-7257
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN60128158
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: