Basic Information
| Provider Information | |||||||||
| NPI: | 1265827489 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | AWASOM | ||||||||
| FirstName: | EMANUEL | ||||||||
| MiddleName: | ANYE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12204 FOXHILL LN | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207152514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014406028 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11301 WILSHIRE BOULEVARD | ||||||||
| Address2: | DEPARTMENT OF VETERANS AFFAIRS GREATER LA HEALTHCARE SY | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104783711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2015 | ||||||||
| LastUpdateDate: | 04/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.