{
"Npi": {
"NPI": "1164151288",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "THOMPSON-BYRUM",
"FirstName": "GRACE",
"MiddleName": "ILEX",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "PA-C",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "BYRUM",
"OtherFirstName": "GRACE",
"OtherMiddleName": "THOMPSON",
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "1065 NE 125TH ST STE 300",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "NORTH MIAMI",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33161-5833",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "888-852-6672",
"MailingAddressFaxNumber": "305-891-4228",
"FirstLinePracticeLocationAddress": "1483 TOBIAS GADSON BLVD STE 201",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHARLESTON",
"PracticeLocationAddressStateName": "SC",
"PracticeLocationAddressPostalCode": "29407-4796",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "843-745-5153",
"PracticeLocationAddressFaxNumber": "305-891-4228",
"EnumerationDate": "06/06/2022",
"LastUpdateDate": "12/26/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "363A00000X",
"TaxonomyName": "Physician Assistant",
"LicenseNumber": "0010-12338",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363A00000X",
"TaxonomyName": "Physician Assistant",
"LicenseNumber": "5019",
"LicenseNumberStateCode": "SC",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}