MEDICARE: ESAM AL NOUMAN LSA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	0136000372	VA

General Provider Information

NPI Number	:	1417253816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ESAM AL NOUMAN LSA

Provider Business Mailing Address
First Line	:	PO BOX 45718
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21297-5718
Country	:	US
Telephone Number	:	214-227-2457
Fax Number	:	214-764-0880

Provider Business Practice Location Address
First Line	:	12011 LEE JACKSON MEMORIAL HWY STE 501
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033-3315
Country	:	US
Telephone Number	:	571-243-1066
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2011
Last Update Date	:	08/14/2023

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Directions to “ ESAM AL NOUMAN LSA” Practice Location

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