| NAME | PROVIDER TYPE | CREDENTIALS | SPECIALTY | STREET ADDRESS | CITY | STATE | ZIP CODE | FACILITY DEFAULT ID NUMBER | STREET ADDRESS LINE 2 | X12 TYPE OF FACILITY | STATE LICENSE # | PRIMARY ID QUALIFIER | MAMMOGRAPHY CERTIFICATION # | LICENSE STATE | SOLE PROPRIETORSHIP | NON-VA PROVIDER | P&C CONTACT NAME | P&C CONTACT PHONE NUMBER | P&C CONTACT PHONE EXTENSION | DATE/TIME OF LAST NPI CHANGE | NPI | TAXONOMY CODE | DATE/TIME LAST FB UPDATE | DATE/TIME ALLOW FB UPDATE |
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