Provider Demographics
NPI:1265827489
Name:AWASOM, EMANUEL ANYE
Entity Type:Individual
Prefix:
First Name:EMANUEL
Middle Name:ANYE
Last Name:AWASOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12204 FOXHILL LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-2514
Mailing Address - Country:US
Mailing Address - Phone:301-440-6028
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BOULEVARD
Practice Address - Street 2:DEPARTMENT OF VETERANS AFFAIRS GREATER LA HEALTHCARE SY
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program