| Name | Value |
|---|---|
| PROVIDER TYPE | Technologists, Technicians and Other Technical Service |
| CLASSIFICATION | Radiologic Technologist |
| AREA OF SPECIALIZATION | Radiation Physicist |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V150311 |
| X12 CODE | 2471R0003N |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255960 |
| EFFECTIVE DATE/TIME |
|