Provider Demographics
NPI:1689120610
Name:HOMER, PATRICK DEAN
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:DEAN
Last Name:HOMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:P DEAN
Other - Middle Name:
Other - Last Name:HOMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1
Mailing Address - Street 2:206 WATER ST
Mailing Address - City:DUSHORE
Mailing Address - State:PA
Mailing Address - Zip Code:18614-0001
Mailing Address - Country:US
Mailing Address - Phone:570-928-8163
Mailing Address - Fax:570-928-8116
Practice Address - Street 1:206 WATER STREET
Practice Address - Street 2:
Practice Address - City:DUSHORE
Practice Address - State:PA
Practice Address - Zip Code:18614-0001
Practice Address - Country:US
Practice Address - Phone:570-928-8163
Practice Address - Fax:570-928-8116
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA011975-L176P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176P00000XOther Service ProvidersFuneral Director