Healthcare Provider Details

I. General information

NPI: 1003964024
Provider Name (Legal Business Name): KENNETH B LAKE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E 3RD ST
DELTA CO
81416-2815
US

IV. Provider business mailing address

PO BOX 10100
DELTA CO
81416-0008
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-7681
  • Fax:
Mailing address:
  • Phone: 970-874-7681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN.0997653-CRNA
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: