| Name | Value |
|---|---|
| PROVIDER TYPE | Technologists, Technicians & Other Technical Service |
| CLASSIFICATION | Perfusionist |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V151002 |
| X12 CODE | 246ZF0200X |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255555 |
| EFFECTIVE DATE/TIME |
|