{
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"NamePrefix": "DR.",
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"FirstLineMailingAddress": "PO BOX 4414",
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"MailingAddressCityName": "POCATELLO",
"MailingAddressStateName": "ID",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "208-219-9927",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "BUILDING 70 NAVAJO DRIVE",
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"PracticeLocationAddressCityName": "FORT HALL",
"PracticeLocationAddressStateName": "ID",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "208-478-3987",
"PracticeLocationAddressFaxNumber": "208-478-4040",
"EnumerationDate": "12/10/2015",
"LastUpdateDate": "03/30/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
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"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "NP-1663A",
"LicenseNumberStateCode": "ID",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}