Basic Information
| Provider Information | |||||||||
| NPI: | 1639402399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOMOTOFF | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 SISTER MARY COLUMBA DR | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960804356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305270414 | ||||||||
| FaxNumber: | 5305287923 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 SISTER MARY COLUMBA DR | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960804356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305270414 | ||||||||
| FaxNumber: | 5305287923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2009 | ||||||||
| LastUpdateDate: | 09/14/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA20521 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.