Healthcare Provider Details

I. General information

NPI: 1336834662
Provider Name (Legal Business Name): SAMANTHA MARIE LEASE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10345 COUNTY ROAD ID
BLUE MOUNDS WI
53517-9646
US

IV. Provider business mailing address

10345 COUNTY ROAD ID
BLUE MOUNDS WI
53517-9646
US

V. Phone/Fax

Practice location:
  • Phone: 608-590-2973
  • Fax: 888-894-5058
Mailing address:
  • Phone: 608-590-2973
  • Fax: 888-894-5058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number81708-21
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number81708
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: