{
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"FirstLineMailingAddress": "3922 N COOL RIVER WAY",
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"FirstLinePracticeLocationAddress": "2204 E LANARK ST STE 100",
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"PracticeLocationAddressCityName": "MERIDIAN",
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"PracticeLocationAddressTelephoneNumber": "208-908-7908",
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"EnumerationDate": "11/09/2022",
"LastUpdateDate": "02/08/2024",
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"NPIReactivationDate": null,
"GenderCode": "M",
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"Taxonomies": {
"Taxonomy": {
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"LicenseNumber": "PT-8166",
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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}
}
}
}