Provider Demographics
NPI:1760523161
Name:HARRISON JR., HOMER MCCOY (PA)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:MCCOY
Last Name:HARRISON JR.
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 GRIMSBY DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-5866
Mailing Address - Country:US
Mailing Address - Phone:925-778-2358
Mailing Address - Fax:
Practice Address - Street 1:3663 ARCH RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95215-8315
Practice Address - Country:US
Practice Address - Phone:209-943-2202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10433363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical