Provider Demographics
NPI:1295474278
Name:DAVES, KENNETH CHARLES JR
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHARLES
Last Name:DAVES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2638 SAGEBRUSH DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2458
Mailing Address - Country:US
Mailing Address - Phone:662-299-1982
Mailing Address - Fax:
Practice Address - Street 1:1600 SPECHT POINT RD STE 127
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4311
Practice Address - Country:US
Practice Address - Phone:970-493-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0997759-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily