| Doctor Name: | MR. HOMER LEO SAM QUEEN |
| NPI Number: | 1295022457 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | C.N.S., C.C.N. M.T. |
| License Number: | MT(ASCP) 052277 |
| Business Practice Address: | 1411 Celebration Ave Unit 310 Celebration, FL - 347474081 |
| Business Phone Number: | 4075668551 |
| Business Fax Number: | 4075668551 |
| Mailing Address: | 7380 W Sand Lake Rd, Suite 500 ORLANDO |
| State: | FL |
| Postal Code: | 328195248 |
| Phone Number: | 7193311848 |
| Fax Number: | 7195481785 |
| NPI Enumeration Date: | 07/07/2011 |
| NPI Last Update Date: | 07/13/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 246QM0706X |
| License Number: | MT(ASCP) 052277 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | TN |
| Taxonomy Type: | Technologists, Technicians & Other Technical Service Providers |
| Taxonomy Classification: | Spec/Tech, Pathology |
| Taxonomy Specialization: | Medical Technologist |
| Taxonomy Definition: | |