{
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"FirstLineMailingAddress": "1036 BRANCHVIEW DR STE 216",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CONCORD",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "28025-0113",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "704-886-1918",
"MailingAddressFaxNumber": "704-257-2049",
"FirstLinePracticeLocationAddress": "11030 S TRYON ST",
"SecondLinePracticeLocationAddress": "SUITE 308",
"PracticeLocationAddressCityName": "CHARLOTTE",
"PracticeLocationAddressStateName": "NC",
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"PracticeLocationAddressTelephoneNumber": "704-504-1004",
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"EnumerationDate": "11/06/2012",
"LastUpdateDate": "08/20/2025",
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
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"AuthorizedOfficialLastName": "PETERS",
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"AuthorizedOfficialTitle": "VICE PRESIDENT",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "919-829-0076",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "213ES0103X",
"TaxonomyName": "Foot & Ankle Surgery Podiatrist",
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"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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}
}
}
}