{
"Npi": {
"NPI": "1558809475",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "WRINKLES",
"FirstName": "BROCK",
"MiddleName": "HARRISON",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "PA",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "6 TRENT JONES CV",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SHERWOOD",
"MailingAddressStateName": "AR",
"MailingAddressPostalCode": "72120-4611",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "501-599-8400",
"MailingAddressFaxNumber": "501-623-5598",
"FirstLinePracticeLocationAddress": "1801 CENTRAL AVE STE A",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "HOT SPRINGS",
"PracticeLocationAddressStateName": "AR",
"PracticeLocationAddressPostalCode": "71901-6800",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "501-623-5598",
"PracticeLocationAddressFaxNumber": "501-623-5516",
"EnumerationDate": "02/11/2017",
"LastUpdateDate": "03/21/2023",
"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": "363AM0700X",
"TaxonomyName": "Medical Physician Assistant",
"LicenseNumber": "PT2017-010",
"LicenseNumberStateCode": "AR",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207QA0401X",
"TaxonomyName": "Addiction Medicine (Family Medicine) Physician",
"LicenseNumber": "PA-720",
"LicenseNumberStateCode": "AR",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}