Healthcare Provider Details

I. General information

NPI: 1558519546
Provider Name (Legal Business Name): JUSTIN HOMER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N LEE AVE 4TH FLOOR
OKLAHOMA CITY OK
73102-1036
US

IV. Provider business mailing address

PO BOX 269064
OKLAHOMA CITY OK
73126-9064
US

V. Phone/Fax

Practice location:
  • Phone: 405-272-7699
  • Fax: 405-272-6662
Mailing address:
  • Phone: 405-231-3857
  • Fax: 405-272-7977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2158
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: