{
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"FirstLineMailingAddress": "6311 SOUTHWEST BLVD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FORT WORTH",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "76132-1063",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "817-738-3390",
"MailingAddressFaxNumber": "817-731-4282",
"FirstLinePracticeLocationAddress": "6311 SOUTHWEST BLVD",
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"PracticeLocationAddressCityName": "FORT WORTH",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "817-738-3390",
"PracticeLocationAddressFaxNumber": "817-731-4282",
"EnumerationDate": "05/19/2006",
"LastUpdateDate": "04/11/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MONAGHAN",
"AuthorizedOfficialFirstName": "PAM",
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"AuthorizedOfficialCredential": "RN",
"AuthorizedOfficialTelephoneNumber": "817-738-3390",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QA1903X",
"TaxonomyName": "Ambulatory Surgical Clinic/Center",
"LicenseNumber": "007141",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}