{
"Npi": {
"NPI": "1235198664",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "X",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "NYSTROM",
"FirstName": "DAREN",
"MiddleName": "MCLEAN",
"NamePrefix": "MR.",
"NameSuffix": null,
"Credential": "MA, ATC, CSCS",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "6012 S 233RD PL",
"SecondLineMailingAddress": "FF204",
"MailingAddressCityName": "KENT",
"MailingAddressStateName": "WA",
"MailingAddressPostalCode": "98032-4855",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "253-879-2813",
"MailingAddressFaxNumber": "253-879-3634",
"FirstLinePracticeLocationAddress": "1500 N WARNER ST",
"SecondLinePracticeLocationAddress": "#1044",
"PracticeLocationAddressCityName": "TACOMA",
"PracticeLocationAddressStateName": "WA",
"PracticeLocationAddressPostalCode": "98416-5000",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "253-879-2813",
"PracticeLocationAddressFaxNumber": "253-879-3634",
"EnumerationDate": "03/23/2006",
"LastUpdateDate": "07/08/2007",
"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": "2255A2300X",
"TaxonomyName": "Athletic Trainer",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}