Provider Demographics
NPI:1235636853
Name:LYTLE, JUSTIN SCOTT (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SCOTT
Last Name:LYTLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5299
Mailing Address - Street 2:MS: 820-5-PCO
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 E 5TH AVE # 1N
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1349
Practice Address - Country:US
Practice Address - Phone:509-342-3100
Practice Address - Fax:509-342-3120
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL60867716207Q00000X
390200000X
WAOP61178536207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program