Healthcare Provider Details

I. General information

NPI: 1932831716
Provider Name (Legal Business Name): MCKENZIE LOUIS SAMUELSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12222 MERIT DR STE 600
DALLAS TX
75251-3294
US

IV. Provider business mailing address

1135 RIVERVIEW RNCH
BRAZORIA TX
77422-7937
US

V. Phone/Fax

Practice location:
  • Phone: 972-715-5000
  • Fax: 972-715-9976
Mailing address:
  • Phone: 616-240-7552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number15894
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1210439
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2341474
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: