Provider Demographics
NPI:1851908800
Name:RICO, TRISTAN (NP)
Entity type:Individual
Prefix:MR
First Name:TRISTAN
Middle Name:
Last Name:RICO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD STE 4500
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2171
Mailing Address - Country:US
Mailing Address - Phone:602-633-6848
Mailing Address - Fax:
Practice Address - Street 1:10815 W MCDOWELL RD STE 202
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5010
Practice Address - Country:US
Practice Address - Phone:623-433-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ222151363L00000X
AZF12240313363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner