{
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"OtherCredential": "MD",
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"FirstLineMailingAddress": "2401 E ST NW",
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"MailingAddressCityName": "WASHINGTON",
"MailingAddressStateName": "DC",
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"MailingAddressCountryCode": "US",
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"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "6365 N CROATAN HWY",
"SecondLinePracticeLocationAddress": "SUITE B",
"PracticeLocationAddressCityName": "KITTY HAWK",
"PracticeLocationAddressStateName": "NC",
"PracticeLocationAddressPostalCode": "27949-3800",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "252-480-6631",
"PracticeLocationAddressFaxNumber": "252-480-6630",
"EnumerationDate": "08/04/2006",
"LastUpdateDate": "03/30/2016",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Family Medicine Physician",
"LicenseNumber": "200101152",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}