Provider Demographics
NPI:1255317434
Name:LASOME, TERRY (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:LASOME
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2157 HARITHY DR
Mailing Address - Street 2:
Mailing Address - City:DUNN LORING
Mailing Address - State:VA
Mailing Address - Zip Code:22027-1056
Mailing Address - Country:US
Mailing Address - Phone:703-992-8841
Mailing Address - Fax:
Practice Address - Street 1:WALTER REED ARMY MEDICAL CENTER
Practice Address - Street 2:6900 GEORGIA AVE NW
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20307-0001
Practice Address - Country:US
Practice Address - Phone:202-782-7580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166806367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN