Healthcare Provider Details

I. General information

NPI: 1962070086
Provider Name (Legal Business Name): LESLIE YAREN RIVERA ROMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO MEMBRILLO SOLARES LUGO CARR 2 K 92 IN
CAMUY PR
00627-9713
US

IV. Provider business mailing address

HC 3 BOX 11509
CAMUY PR
00627-9713
US

V. Phone/Fax

Practice location:
  • Phone: 787-240-5279
  • Fax:
Mailing address:
  • Phone: 787-240-5279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number22343
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: