{
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"EIN": null,
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"NameSuffix": null,
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"OtherCredential": "PHYSICIAN ASSISTANT",
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"FirstLineMailingAddress": "25902 148TH AVE",
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"MailingAddressCityName": "ROSEDALE",
"MailingAddressStateName": "NY",
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"MailingAddressCountryCode": "US",
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"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "25902 148TH AVE",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "646-712-2606",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/06/2009",
"LastUpdateDate": "03/08/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Physician Assistant",
"LicenseNumber": "011145",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}