{
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"FirstLineMailingAddress": "5055 MONROE FOREST DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "JACKSONVILLE",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32257-2204",
"MailingAddressCountryCode": "US",
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"FirstLinePracticeLocationAddress": "14810 OLD SAINT AUGUSTINE RD",
"SecondLinePracticeLocationAddress": "SUITE 201",
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"PracticeLocationAddressStateName": "FL",
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"PracticeLocationAddressTelephoneNumber": "904-292-0863",
"PracticeLocationAddressFaxNumber": "904-212-0884",
"EnumerationDate": "12/30/2011",
"LastUpdateDate": "02/16/2012",
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CLARK",
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"AuthorizedOfficialCredential": "PA-C",
"AuthorizedOfficialTelephoneNumber": "904-322-1140",
"Taxonomies": {
"Taxonomy": {
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"LicenseNumber": "ME96311",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}