{
"Npi": {
"NPI": "1053789610",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SUNY UPSTATE",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "5104 WATERFORD WOOD WAY",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FAYETTEVILLE",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "13066-9799",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "607-759-7462",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "90 PRESIDENTIAL PLZ",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SYRACUSE",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "13202-2240",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "315-464-3833",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "09/11/2015",
"LastUpdateDate": "09/11/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KENNEY",
"AuthorizedOfficialFirstName": "VIKTORIA",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "FNP",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "FNP",
"AuthorizedOfficialTelephoneNumber": "607-759-7462",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261Q00000X",
"TaxonomyName": "Clinic/Center",
"LicenseNumber": "F339820-1",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}