{
"Npi": {
"NPI": "1245255686",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "BURK",
"FirstName": "RICKY",
"MiddleName": "R",
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "OD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 1506",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CHEHALIS",
"MailingAddressStateName": "WA",
"MailingAddressPostalCode": "98532-0409",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "360-242-3008",
"MailingAddressFaxNumber": "360-807-7687",
"FirstLinePracticeLocationAddress": "19801 SW 72ND AVE STE 150",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "TUALATIN",
"PracticeLocationAddressStateName": "OR",
"PracticeLocationAddressPostalCode": "97062-8347",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "503-691-2283",
"PracticeLocationAddressFaxNumber": "503-691-5981",
"EnumerationDate": "07/13/2006",
"LastUpdateDate": "11/04/2020",
"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": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": "ATI2559",
"LicenseNumberStateCode": "OR",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}