{
"Npi": {
"NPI": "1831325752",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "WILSON",
"FirstName": "MICHAEL",
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": "P.A.",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "872 W HIGHWAY 40",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "VERNAL",
"MailingAddressStateName": "UT",
"MailingAddressPostalCode": "84078-2416",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "435-789-6677",
"MailingAddressFaxNumber": "435-789-6678",
"FirstLinePracticeLocationAddress": "872 W HIGHWAY 40",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "VERNAL",
"PracticeLocationAddressStateName": "UT",
"PracticeLocationAddressPostalCode": "84078-2416",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "435-789-6677",
"PracticeLocationAddressFaxNumber": "435-789-6678",
"EnumerationDate": "06/05/2009",
"LastUpdateDate": "10/28/2020",
"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": "6739131-1206",
"LicenseNumberStateCode": "UT",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}