Provider Demographics
NPI:1841534591
Name:QUEENSBOURROW, OMAR S (PA)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:S
Last Name:QUEENSBOURROW
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 GREENVIEW TER
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-8755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5185 OLD NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-3244
Practice Address - Country:US
Practice Address - Phone:404-763-9300
Practice Address - Fax:404-763-9306
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9106708363AM0700X
GA006678363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical