{
"Npi": {
"NPI": "1205580701",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "MASON",
"FirstName": "THEOPHILUS",
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": "FNP",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "MASON",
"OtherFirstName": "THEOPHILUS",
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": "FNP",
"OtherLastNameTypeCode": "5",
"FirstLineMailingAddress": "250 W BONITA AVE STE 100",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "POMONA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "91767-1863",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "909-392-2002",
"MailingAddressFaxNumber": "626-795-4768",
"FirstLinePracticeLocationAddress": "250 W BONITA AVE STE 100",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "POMONA",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "91767-1863",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "909-392-2002",
"PracticeLocationAddressFaxNumber": "626-795-4768",
"EnumerationDate": "02/04/2022",
"LastUpdateDate": "12/12/2024",
"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": "363LF0000X",
"TaxonomyName": "Family Nurse Practitioner",
"LicenseNumber": "209023392",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363LF0000X",
"TaxonomyName": "Family Nurse Practitioner",
"LicenseNumber": "NP95029519",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}