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General NPI Number Information
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NPI Number | 1891115697
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Entity Type | Individual
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Provider Name | MICAH PEARCE MCKENZIE CRNA
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Gender | Male
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Dates
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Enumeration Date | 04/18/2014
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Last Update Date | 05/14/2014
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Provider Practice Location Address
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Address Line | 3901 S 7TH ST
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City | TERRE HAUTE
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State | IN
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Zip | 47802-5709
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Country | US
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Telephone | 727-437-3530
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Fax | 727-498-1159
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Provider Business Mailing Address
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Address Line | 4024 S WILLOWBROOK CT
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City | TERRE HAUTE
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State | IN
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Zip | 47802-8871
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Country | US
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Telephone | 801-884-3325
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 28213679A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 28213679A
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License Number State | IN
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