{
  "npi": "1841583788",
  "enumeration_type": "NPI-1",
  "basic": {
    "certification_date": "2024-01-11",
    "credential": "PA-C",
    "enumeration_date": "2011-05-25",
    "first_name": "RICHARD",
    "last_name": "WALLACE",
    "last_updated": "2024-01-11",
    "middle_name": "JEREMY",
    "name_prefix": "Mr.",
    "sex": "M",
    "sole_proprietor": "NO",
    "status": "A"
  },
  "addresses": [
    {
      "address_1": "13649 CHURCH STREET",
      "address_purpose": "LOCATION",
      "address_type": "DOM",
      "city": "WILLISTON",
      "country_code": "US",
      "country_name": "United States",
      "fax_number": "803-266-0042",
      "postal_code": "29853",
      "state": "SC",
      "telephone_number": "803-266-0060"
    },
    {
      "address_1": "86 WREN ST",
      "address_purpose": "MAILING",
      "address_type": "DOM",
      "city": "BARNWELL",
      "country_code": "US",
      "country_name": "United States",
      "fax_number": "803-259-3250",
      "postal_code": "298121529",
      "state": "SC",
      "telephone_number": "803-259-5762"
    }
  ],
  "taxonomies": [
    {
      "code": "363A00000X",
      "desc": "Physician Assistant",
      "license": null,
      "primary": true,
      "state": null,
      "taxonomy_group": ""
    }
  ],
  "compliance": {
    "oig_leie_exclusion": {
      "excluded": false,
      "status": "CLEAR",
      "matches": [],
      "totalDbRecords": 84224
    },
    "cms_pecos_eligibility": {
      "note": "Not listed in CMS Order & Referring PECOS file or institutional NPI-2"
    }
  },
  "medicare_utilization": null,
  "enrichment": {
    "plain_english_specialty": "Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Physician Assistant",
    "certifying_board": "State Medical / Healthcare Licensing Board & National Specialty Board",
    "cms_medicare_crosswalk": [
      {
        "medicare_code": "97",
        "medicare_type": "Physician Assistant"
      }
    ]
  }
}