Provider Demographics
NPI:1417253816
Name:AL NOUMAN, ESAM (LSA)
Entity Type:Individual
Prefix:
First Name:ESAM
Middle Name:
Last Name:AL NOUMAN
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45718
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-5718
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:214-764-0880
Practice Address - Street 1:12011 LEE JACKSON MEMORIAL HWY STE 501
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3315
Practice Address - Country:US
Practice Address - Phone:571-243-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000372246ZC0007X
DCSA0069363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical