Healthcare Provider Details

I. General information

NPI: 1932053873
Provider Name (Legal Business Name): DERRICK DEVON FARGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16221 N 7TH DR
PHOENIX AZ
85023-7900
US

IV. Provider business mailing address

16221 N 7TH DR
PHOENIX AZ
85023-7900
US

V. Phone/Fax

Practice location:
  • Phone: 623-312-6491
  • Fax:
Mailing address:
  • Phone: 480-709-2868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberD09261199
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberD09261199
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: