{
"Npi": {
"NPI": "1649611476",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "DERMATOLOGY AND PLASTIC SURGERY OF ARIZONA LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "150 S CORONADO DR STE 110",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SIERRA VISTA",
"MailingAddressStateName": "AZ",
"MailingAddressPostalCode": "85635-6352",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "520-458-1787",
"MailingAddressFaxNumber": "520-458-1519",
"FirstLinePracticeLocationAddress": "150 S CORONADO DR STE 110",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SIERRA VISTA",
"PracticeLocationAddressStateName": "AZ",
"PracticeLocationAddressPostalCode": "85635-6352",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "520-458-1787",
"PracticeLocationAddressFaxNumber": "520-458-1519",
"EnumerationDate": "07/09/2013",
"LastUpdateDate": "10/08/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MOENSTER",
"AuthorizedOfficialFirstName": "JAMIE",
"AuthorizedOfficialMiddleName": "M",
"AuthorizedOfficialTitle": "MEMBER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.O.",
"AuthorizedOfficialTelephoneNumber": "520-458-1787",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "207N00000X",
"TaxonomyName": "Dermatology Physician",
"LicenseNumber": "006021",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "208200000X",
"TaxonomyName": "Plastic Surgery Physician",
"LicenseNumber": "006018",
"LicenseNumberStateCode": "AZ",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207ND0101X",
"TaxonomyName": "MOHS-Micrographic Surgery Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}