Provider Demographics
NPI:1821119553
Name:QUEEN, MICHAEL LANCE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LANCE
Last Name:QUEEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4134 B CHARLOTTE HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710
Mailing Address - Country:US
Mailing Address - Phone:919-440-9554
Mailing Address - Fax:
Practice Address - Street 1:1190 FILBERT HWY
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-9324
Practice Address - Country:US
Practice Address - Phone:803-628-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10863207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC82152Medicare UPIN