Provider Demographics
NPI:1356486021
Name:HOMER, RANDALL SCOTT (NP, PA)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:SCOTT
Last Name:HOMER
Suffix:
Gender:M
Credentials:NP, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9770 WOODHOLLOW WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2724
Mailing Address - Country:US
Mailing Address - Phone:916-362-5952
Mailing Address - Fax:
Practice Address - Street 1:3941 J ST
Practice Address - Street 2:SUITE 354
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3624
Practice Address - Country:US
Practice Address - Phone:916-733-6870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19058363A00000X
CA17075363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health