| Name | Value |
|---|---|
| PROVIDER TYPE | Technologists, Technicians & Other Technical Service Providers |
| CLASSIFICATION | Specialist/Technologist, Pathology |
| AREA OF SPECIALIZATION | Laboratory Management, Diplomate |
| STATUS | Active |
| VA CODE | V150104 |
| X12 CODE | 246QL0901X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255639 |
| EFFECTIVE DATE/TIME |
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