| Name | Value |
|---|---|
| PROVIDER TYPE | Physician Assistants & Advanced Practice Nursing Providers |
| CLASSIFICATION | Nurse Practitioner |
| AREA OF SPECIALIZATION | Adult Health |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V100618 |
| X12 CODE | 363LA2200X |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253359 |
| EFFECTIVE DATE/TIME |
|