Provider Demographics
NPI:1528020948
Name:QUEEN, DEBORAH (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:
Last Name:QUEEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-8460
Mailing Address - Fax:704-384-8465
Practice Address - Street 1:1994 WELLNESS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-7767
Practice Address - Country:US
Practice Address - Phone:704-384-8460
Practice Address - Fax:704-384-8465
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801029208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891152QMedicaid
NCG66480Medicare UPIN
NC2280178Medicare ID - Type Unspecified