{
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"FirstLineMailingAddress": "641 GROOMS RD # 186",
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"MailingAddressStateName": "NY",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "607-316-1583",
"MailingAddressFaxNumber": "607-316-1583",
"FirstLinePracticeLocationAddress": "632 PLANK RD STE 103",
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"PracticeLocationAddressCityName": "CLIFTON PARK",
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"PracticeLocationAddressTelephoneNumber": "518-414-5706",
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"EnumerationDate": "11/28/2025",
"LastUpdateDate": "11/28/2025",
"NPIDeactivationReasonCode": null,
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CARSON",
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"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialCredential": "PA",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Physician Assistant",
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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}
}
}
}