{
"Npi": {
"NPI": "1053898833",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SPORTSMEDICINE OUTREACH SPECIALIST",
"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": "835 W WARNER RD",
"SecondLineMailingAddress": "STE 101-448",
"MailingAddressCityName": "GILBERT",
"MailingAddressStateName": "AZ",
"MailingAddressPostalCode": "85233-7269",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "480-980-8206",
"MailingAddressFaxNumber": "480-281-5224",
"FirstLinePracticeLocationAddress": "835 W WARNER RD",
"SecondLinePracticeLocationAddress": "STE 101-448",
"PracticeLocationAddressCityName": "GILBERT",
"PracticeLocationAddressStateName": "AZ",
"PracticeLocationAddressPostalCode": "85233-7269",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "602-689-9588",
"PracticeLocationAddressFaxNumber": "480-281-5224",
"EnumerationDate": "07/24/2018",
"LastUpdateDate": "10/30/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "OVERLIN",
"AuthorizedOfficialFirstName": "MATTHEW",
"AuthorizedOfficialMiddleName": "DEAN",
"AuthorizedOfficialTitle": "PHYSICIAN ASSISTANT",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "PA-C",
"AuthorizedOfficialTelephoneNumber": "602-689-9588",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "363AS0400X",
"TaxonomyName": "Surgical Physician Assistant",
"LicenseNumber": "3233",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}