Basic Information
| Provider Information | |||||||||
| NPI: | 1699188656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEOTAUD-MORENO | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | GM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEOTAUD | ||||||||
| OtherFirstName: | JANE | ||||||||
| OtherMiddleName: | GM | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 785 5TH AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7177096529 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172682332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177655085 | ||||||||
| FaxNumber: | 7177655066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2014 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD452196 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01361232 | 01 | PA | RRMC | OTHER | 102926634 | 05 | PA | MEDICAID |