{
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"FirstLineMailingAddress": "1600 W UNIVERSITY AVE STE 105",
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"MailingAddressFaxNumber": "928-240-9212",
"FirstLinePracticeLocationAddress": "1600 W UNIVERSITY AVE STE 105&110",
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"PracticeLocationAddressCityName": "FLAGSTAFF",
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"EnumerationDate": "03/29/2021",
"LastUpdateDate": "05/29/2022",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
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"Gender": null,
"AuthorizedOfficialLastName": "KORTSEN",
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"AuthorizedOfficialCredential": "OD",
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"Taxonomies": {
"Taxonomy": {
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"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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}
}
}
}