Healthcare Provider Details

I. General information

NPI: 1841534591
Provider Name (Legal Business Name): OMAR S QUEENSBOURROW PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5185 OLD NATIONAL HWY
ATLANTA GA
30349-3244
US

IV. Provider business mailing address

198 GREENVIEW TER
MACON GA
31220-8755
US

V. Phone/Fax

Practice location:
  • Phone: 404-763-9300
  • Fax: 404-763-9306
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9106708
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number006678
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: