Provider Demographics
NPI:1659625911
Name:OMAR QUEENSBOURROW
Entity Type:Organization
Organization Name:OMAR QUEENSBOURROW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEENSBOURROW
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:800-507-8874
Mailing Address - Street 1:305 HOSPITAL DRIVE
Mailing Address - Street 2:APT 106
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217
Mailing Address - Country:US
Mailing Address - Phone:478-746-4646
Mailing Address - Fax:
Practice Address - Street 1:305 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217
Practice Address - Country:US
Practice Address - Phone:478-746-4646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106708282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital