Provider Demographics
NPI:1760055099
Name:SEGUN, RICO ANDREW (ACNP)
Entity Type:Individual
Prefix:
First Name:RICO
Middle Name:ANDREW
Last Name:SEGUN
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8005 W REDBIRD RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-6264
Mailing Address - Country:US
Mailing Address - Phone:602-716-1967
Mailing Address - Fax:
Practice Address - Street 1:6036 N 19TH AVE STE 506
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2143
Practice Address - Country:US
Practice Address - Phone:602-841-0741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ235620363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care