Provider Demographics
NPI:1396438826
Name:RICO, NICHOLAS GOPAL (CAA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GOPAL
Last Name:RICO
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19535 NW 226TH TER
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-0664
Mailing Address - Country:US
Mailing Address - Phone:352-215-5081
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA815367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118366900Medicaid