Provider Demographics
NPI:1639855331
Name:AMICO, DEIDRA (CPT, CET)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:AMICO
Suffix:
Gender:F
Credentials:CPT, CET
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45096 W BUCKHORN TRL
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-4171
Mailing Address - Country:US
Mailing Address - Phone:520-431-2518
Mailing Address - Fax:
Practice Address - Street 1:45096 W BUCKHORN TRL
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139-4171
Practice Address - Country:US
Practice Address - Phone:520-431-2518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJR9H3P3P4246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty