Provider Demographics
NPI:1013934827
Name:STA ROMANA, LEILANE U (MD)
Entity Type:Individual
Prefix:
First Name:LEILANE
Middle Name:U
Last Name:STA ROMANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6127 GREEN BAY RD
Mailing Address - Street 2:#200
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2929
Mailing Address - Country:US
Mailing Address - Phone:262-658-3706
Mailing Address - Fax:262-658-1751
Practice Address - Street 1:6127 GREEN BAY RD
Practice Address - Street 2:#200
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2929
Practice Address - Country:US
Practice Address - Phone:262-658-3706
Practice Address - Fax:262-658-1751
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32522207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31952600Medicaid
WI31952600Medicaid
WI322500133Medicare PIN
WI000032237Medicare PIN