{
"Npi": {
"NPI": "1235252289",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "REBISH",
"FirstName": "SANDRA",
"MiddleName": "LEE",
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "MD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "LEE",
"OtherFirstName": "SANDRA",
"OtherMiddleName": null,
"OtherNamePrefix": "DR.",
"OtherNameSuffix": null,
"OtherCredential": "MD",
"OtherLastNameTypeCode": "5",
"FirstLineMailingAddress": "801 YORK ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MANITOWOC",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "54220-4630",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "920-663-9008",
"MailingAddressFaxNumber": "920-684-1439",
"FirstLinePracticeLocationAddress": "859 E FOOTHILL BLVD STE B",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "UPLAND",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "91786-4085",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "909-981-8929",
"PracticeLocationAddressFaxNumber": "909-946-9740",
"EnumerationDate": "04/06/2007",
"LastUpdateDate": "01/20/2023",
"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": "207ND0101X",
"TaxonomyName": "MOHS-Micrographic Surgery Physician",
"LicenseNumber": "A81296",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207N00000X",
"TaxonomyName": "Dermatology Physician",
"LicenseNumber": "A81296",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}