Healthcare Provider Details

I. General information

NPI: 1134519176
Provider Name (Legal Business Name): LESLIE N AWASOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE DEPARTMENT OF ANESTHESIOLOGY
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

2130 COLONEL WAY
ODENTON MD
21113-1092
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-7584
  • Fax:
Mailing address:
  • Phone: 301-655-4708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR189245
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: