{
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"FirstLinePracticeLocationAddress": "135 BRADFORD SQ STE B",
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"EnumerationDate": "04/12/2025",
"LastUpdateDate": "04/12/2025",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "OTUBAGA",
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"AuthorizedOfficialTelephoneNumber": "417-652-2486",
"Taxonomies": {
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"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}