{
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"EIN": null,
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"MiddleName": null,
"NamePrefix": "MR.",
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"FirstLineMailingAddress": "308 ODD RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "POQUOSON",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "23662-2051",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "931-809-0529",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "104 PRODUCTION DR",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "YORKTOWN",
"PracticeLocationAddressStateName": "VA",
"PracticeLocationAddressPostalCode": "23693-4024",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "757-528-3040",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "02/12/2020",
"LastUpdateDate": "02/13/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
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"AuthorizedOfficialTitle": null,
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "225700000X",
"TaxonomyName": "Massage Therapist",
"LicenseNumber": "0019016993",
"LicenseNumberStateCode": "VA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}