Provider Demographics
NPI:1891115697
Name:MCKENZIE, MICAH PEARCE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICAH
Middle Name:PEARCE
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 S WILLOWBROOK CT
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-8871
Mailing Address - Country:US
Mailing Address - Phone:801-884-3325
Mailing Address - Fax:
Practice Address - Street 1:3901 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5709
Practice Address - Country:US
Practice Address - Phone:727-437-3530
Practice Address - Fax:727-498-1159
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28213679A163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse