{
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"LastName": null,
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"FirstLineMailingAddress": "21075 SWENSON DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WAUKESHA",
"MailingAddressStateName": "WI",
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"MailingAddressCountryCode": "US",
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"FirstLinePracticeLocationAddress": "21075 SWENSON DR",
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"PracticeLocationAddressCityName": "WAUKESHA",
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"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "08/13/2013",
"LastUpdateDate": "08/13/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ELLENSON",
"AuthorizedOfficialFirstName": "NICHOLAS",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "262-754-6850",
"Taxonomies": {
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"TaxonomyName": "Clinic/Center",
"LicenseNumber": "4932 - 12",
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}