{
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"FirstLineMailingAddress": "403 E 11TH ST",
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"MailingAddressCityName": "PANAMA CITY",
"MailingAddressStateName": "FL",
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"MailingAddressFaxNumber": "850-767-3353",
"FirstLinePracticeLocationAddress": "793 W STATE ST",
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"PracticeLocationAddressCityName": "COLUMBUS",
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"EnumerationDate": "06/15/2008",
"LastUpdateDate": "09/19/2019",
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
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"Taxonomies": {
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}