Provider Demographics
NPI:1962070086
Name:RIVERA ROMAN, LESLIE YAREN
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:YAREN
Last Name:RIVERA ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 3 BOX 11509
Mailing Address - Street 2:
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627-9713
Mailing Address - Country:US
Mailing Address - Phone:787-240-5279
Mailing Address - Fax:
Practice Address - Street 1:BO MEMBRILLO SOLARES LUGO CARR 2 K 92 IN
Practice Address - Street 2:
Practice Address - City:CAMUY
Practice Address - State:PR
Practice Address - Zip Code:00627-9713
Practice Address - Country:US
Practice Address - Phone:787-240-5279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22343208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice