Provider Demographics
NPI:1790167757
Name:HOMER, KATHERINE (DO)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:HOMER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-302-9342
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4400 E FLAMINGO AVE STE 200
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9203
Practice Address - Country:US
Practice Address - Phone:208-302-2700
Practice Address - Fax:208-302-2725
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021794208600000X
ORDO218105208600000X
IDO-1915208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery