Healthcare Provider Details

I. General information

NPI: 1679176051
Provider Name (Legal Business Name): BRANDON LYNN KENTOPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4597
US

IV. Provider business mailing address

6941 OAK ST
ARVADA CO
80004-1455
US

V. Phone/Fax

Practice location:
  • Phone: 316-253-3290
  • Fax: 303-602-2719
Mailing address:
  • Phone: 316-253-3290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number209.022117
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberAPN.0997291-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: