Provider Demographics
NPI:1366686800
Name:LAKE, KAYSE LEE (DPM)
Entity Type:Individual
Prefix:
First Name:KAYSE
Middle Name:LEE
Last Name:LAKE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1266 ESCALANTE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303
Mailing Address - Country:US
Mailing Address - Phone:970-259-5303
Mailing Address - Fax:970-253-3510
Practice Address - Street 1:1266 ESCALANTE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303
Practice Address - Country:US
Practice Address - Phone:970-253-5303
Practice Address - Fax:970-259-3510
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM348213ES0103X
OH36.003558213ES0103X
UT5063880-0501213ES0103X
CO710213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07501552Medicaid
CO289423YR9UMedicare PIN
CO07501552Medicaid