| Name | Value |
|---|---|
| PROVIDER TYPE | Nursing Service |
| CLASSIFICATION | Registered Nurse |
| AREA OF SPECIALIZATION | Post-Anesthesia |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V070946 |
| X12 CODE | 163WP2200N |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252858 |
| EFFECTIVE DATE/TIME |
|