MEDICARE: DR. BRYAN LAZETTE CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	11017174	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639839988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYAN LAZETTE CRNA

Provider Business Mailing Address
First Line	:	4840 SEASCAPE WAY APT 210
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-0627
Country	:	US
Telephone Number	:	727-504-6618
Fax Number	:

Provider Business Practice Location Address
First Line	:	3625 UNIVERSITY BLVD S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4222
Country	:	US
Telephone Number	:	727-504-6618
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2021
Last Update Date	:	01/18/2022

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