| Name | Value |
|---|---|
| PROVIDER TYPE | Physician Assistants & Advanced Practice Nursing |
| CLASSIFICATION | Nurse Practitioner |
| AREA OF SPECIALIZATION | Pediatrics: Acute Care |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V100612 |
| X12 CODE | 363LP0223N |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253326 |
| EFFECTIVE DATE/TIME |
|