{
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"FirstLineMailingAddress": "2537 MOUNTAIN LAKE RD",
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"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "27205-4497",
"MailingAddressCountryCode": "US",
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"FirstLinePracticeLocationAddress": "2401 S SIDE BLVD",
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"EnumerationDate": "04/05/2006",
"LastUpdateDate": "12/19/2025",
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "EVANS",
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"AuthorizedOfficialCredential": "MD",
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"Taxonomies": {
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"PrimaryTaxonomySwitch": "Y"
}
},
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}
}
}
}