Provider Demographics
NPI:1558519546
Name:HOMER, JUSTIN (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:HOMER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 269064
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9064
Mailing Address - Country:US
Mailing Address - Phone:405-231-3857
Mailing Address - Fax:405-272-7977
Practice Address - Street 1:1000 N LEE AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1036
Practice Address - Country:US
Practice Address - Phone:405-272-7699
Practice Address - Fax:405-272-6662
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK2158363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical