MEDICARE: DERRICK DEVON FARGO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist		AZ

General Provider Information

NPI Number	:	1932053873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERRICK DEVON FARGO

Provider Business Mailing Address
First Line	:	1801 W MOUNTAIN VIEW RD APT 7
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-0922
Country	:	US
Telephone Number	:	623-312-6491
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 W MOUNTAIN VIEW RD APT 7
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-0922
Country	:	US
Telephone Number	:	623-312-6491
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2026
Last Update Date	:	03/12/2026

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Directions to “ DERRICK DEVON FARGO ” Practice Location

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