Provider Demographics
NPI:1669768040
Name:NABORS, KENNETH M
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:M
Last Name:NABORS
Suffix:
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 1:440 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2642
Mailing Address - Country:US
Mailing Address - Phone:928-443-1991
Mailing Address - Fax:928-771-2352
Practice Address - Street 1:3200 W THIRD ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2076
Practice Address - Country:US
Practice Address - Phone:928-853-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2611059174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist