{
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"EIN": null,
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"OtherCredential": "PA-C",
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"FirstLineMailingAddress": "1575 S RAILROAD AVE",
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"MailingAddressCityName": "CRESCENT CITY",
"MailingAddressStateName": "CA",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "707-464-8335",
"MailingAddressFaxNumber": "707-464-8339",
"FirstLinePracticeLocationAddress": "4715 VALLEY EAST BLVD",
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"PracticeLocationAddressTelephoneNumber": "707-822-3376",
"PracticeLocationAddressFaxNumber": "707-822-5053",
"EnumerationDate": "03/23/2009",
"LastUpdateDate": "06/11/2019",
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"NPIReactivationDate": null,
"GenderCode": "M",
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"Taxonomies": {
"Taxonomy": {
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}