{
"Npi": {
"NPI": "1215983879",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "WOLLUM",
"FirstName": "RONALD",
"MiddleName": "E",
"NamePrefix": "MR.",
"NameSuffix": "III",
"Credential": "PAC",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "3070 PRESIDENTIAL DR",
"SecondLineMailingAddress": "SUITE 200",
"MailingAddressCityName": "FAIRBORN",
"MailingAddressStateName": "OH",
"MailingAddressPostalCode": "45324-6293",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "937-429-2160",
"MailingAddressFaxNumber": "937-426-5663",
"FirstLinePracticeLocationAddress": "1416 W 1ST ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SPRINGFIELD",
"PracticeLocationAddressStateName": "OH",
"PracticeLocationAddressPostalCode": "45504",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "937-322-1700",
"PracticeLocationAddressFaxNumber": "937-322-8070",
"EnumerationDate": "05/25/2006",
"LastUpdateDate": "08/23/2018",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "363A00000X",
"TaxonomyName": "Physician Assistant",
"LicenseNumber": "PA9106675",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363A00000X",
"TaxonomyName": "Physician Assistant",
"LicenseNumber": "50002301",
"LicenseNumberStateCode": "OH",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}