| Name | Value |
|---|---|
| PROVIDER TYPE | Physician Assistants & Advanced Practice Nursing Providers |
| CLASSIFICATION | Physician Assistant |
| AREA OF SPECIALIZATION | Surgical |
| STATUS | Active |
| VA CODE | V100200 |
| X12 CODE | 363AS0400X |
| SPECIALTY CODE | 97 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253344 |
| EFFECTIVE DATE/TIME |
|