{
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"FirstLineMailingAddress": "2990 E NORTHERN AVE STE C103",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PHOENIX",
"MailingAddressStateName": "AZ",
"MailingAddressPostalCode": "85028-4839",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "602-772-2382",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "8752 E VIA DE COMMERCIO STE 2",
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"PracticeLocationAddressCityName": "SCOTTSDALE",
"PracticeLocationAddressStateName": "AZ",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "602-772-2382",
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"EnumerationDate": "04/22/2021",
"LastUpdateDate": "04/22/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CANULLA",
"AuthorizedOfficialFirstName": "MARCO",
"AuthorizedOfficialMiddleName": "VALERIO",
"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialTelephoneNumber": "602-571-6521",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "208600000X",
"TaxonomyName": "Surgery Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"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."
}
}
}
}