Healthcare Provider Details

I. General information

NPI: 1366686800
Provider Name (Legal Business Name): KAYSE LEE LAKE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1266 ESCALANTE DR SUITE 201
DURANGO CO
81303
US

IV. Provider business mailing address

1266 ESCALANTE DR SUITE 201
DURANGO CO
81303
US

V. Phone/Fax

Practice location:
  • Phone: 970-253-5303
  • Fax: 970-259-3510
Mailing address:
  • Phone: 970-259-5303
  • Fax: 970-253-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD348
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number710
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number348
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5063880-0501
License Number StateUT
# 5
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD.0000710
License Number StateCO
# 6
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5063880-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: