| Name | Value |
|---|---|
| PROVIDER TYPE | Physician Assistants & Advanced Practice Nursing Providers |
| CLASSIFICATION | Student, Nurse Practitioner |
| STATUS | Active |
| VA CODE | V100501 |
| X12 CODE | 390200000X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5330399 |
| EFFECTIVE DATE/TIME |
|