| Name | Value |
|---|---|
| PROVIDER TYPE | Physicians (Other Roles) |
| CLASSIFICATION | Physician/Osteopath |
| AREA OF SPECIALIZATION | Supplier |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V160102 |
| X12 CODE | 353BS0900N |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5254994 |
| EFFECTIVE DATE/TIME |
|