Healthcare Provider Details

I. General information

NPI: 1760523161
Provider Name (Legal Business Name): HOMER MCCOY HARRISON JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3663 ARCH RD
STOCKTON CA
95215-8315
US

IV. Provider business mailing address

2421 GRIMSBY DR
ANTIOCH CA
94509-5866
US

V. Phone/Fax

Practice location:
  • Phone: 209-943-2202
  • Fax:
Mailing address:
  • Phone: 925-778-2358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: