| Name | Value |
|---|---|
| PROVIDER TYPE | Technologists, Technicians & Other Technical Service Providers |
| CLASSIFICATION | Technician, Other |
| AREA OF SPECIALIZATION | Darkroom |
| STATUS | Inactive |
| DATE INACTIVATED | 2023-04-03 00:00:00 |
| VA CODE | V150303 |
| X12 CODE | 2472D0500X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255744 |
| EFFECTIVE DATE/TIME |
|