{
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"FirstLineMailingAddress": "PO BOX 3360",
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"MailingAddressCityName": "PORTLAND",
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"FirstLinePracticeLocationAddress": "1620 COOPER POINT ROAD NW",
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"PracticeLocationAddressTelephoneNumber": "360-486-6710",
"PracticeLocationAddressFaxNumber": "360-956-1643",
"EnumerationDate": "11/20/2006",
"LastUpdateDate": "02/04/2022",
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"NPIReactivationDate": null,
"GenderCode": "M",
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"Taxonomies": {
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}