{
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"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "688 ANTELOPE DR LOT 21",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ROCK SPRINGS",
"MailingAddressStateName": "WY",
"MailingAddressPostalCode": "82901-3016",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "307-274-7500",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "400 N 100 E",
"SecondLinePracticeLocationAddress": "SUITE 205",
"PracticeLocationAddressCityName": "GREEN RIVER",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "307-362-2424",
"PracticeLocationAddressFaxNumber": "307-222-0614",
"EnumerationDate": "02/19/2016",
"LastUpdateDate": "09/03/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
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"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
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"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}