Basic Information
| Provider Information | |||||||||
| NPI: | 1932831716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMUELSON | ||||||||
| FirstName: | MCKENZIE | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 HANCOCK ST APT 1403 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021712478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162407552 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 FOGG RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021902432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816248000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2022 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN2341474 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.