| Name | Value |
|---|---|
| PROVIDER TYPE | Technologists, Technicians and Other Technical Service |
| CLASSIFICATION | Specialist/Technologist, Cardiology |
| AREA OF SPECIALIZATION | Perfusionist |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V150207 |
| X12 CODE | 246VP3600N |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255930 |
| EFFECTIVE DATE/TIME |
|