Provider Demographics
NPI:1477918126
Name:HOMER, EDGAR JOHNSON (MA)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:JOHNSON
Last Name:HOMER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8933 S 253RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2299
Mailing Address - Country:US
Mailing Address - Phone:480-529-3630
Mailing Address - Fax:
Practice Address - Street 1:8933 S 253RD EAST AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-2299
Practice Address - Country:US
Practice Address - Phone:480-529-3630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator