Provider Demographics
NPI:1134519176
Name:AWASOM, LESLIE N
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:N
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 1:2130 COLONEL WAY
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1092
Mailing Address - Country:US
Mailing Address - Phone:301-655-4708
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-7584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR189245367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered