{
"Npi": {
"NPI": "1932577673",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "HIGHLAND SURGICAL ASSISTANT, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "11340 LAKEFIELD DR",
"SecondLineMailingAddress": "SUITE 200",
"MailingAddressCityName": "JOHNS CREEK",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30097-1714",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "770-629-8289",
"MailingAddressFaxNumber": "404-393-9515",
"FirstLinePracticeLocationAddress": "11340 LAKEFIELD DR",
"SecondLinePracticeLocationAddress": "SUITE 200",
"PracticeLocationAddressCityName": "JOHNS CREEK",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30097-1714",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "770-629-8289",
"PracticeLocationAddressFaxNumber": "404-393-9515",
"EnumerationDate": "09/11/2015",
"LastUpdateDate": "09/02/2016",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MITCHELL",
"AuthorizedOfficialFirstName": "WESLEY",
"AuthorizedOfficialMiddleName": "LAGREGORY",
"AuthorizedOfficialTitle": "CEO",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "770-629-8289",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "363AS0400X",
"TaxonomyName": "Surgical Physician Assistant",
"LicenseNumber": "3245",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}