| Name | Value |
|---|---|
| PROVIDER TYPE | Technologists, Technicians and Other Technical Service |
| CLASSIFICATION | Radiologic Sciences |
| STATUS | Inactive |
| DATE INACTIVATED | 1998-10-20 00:00:00 |
| VA CODE | V150300 |
| reserved | A, Try V1503-- |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255825 |
| EFFECTIVE DATE/TIME |
|