| Name | Value |
|---|---|
| PROVIDER TYPE | Physician Assistants & Advanced Practice Nursing Providers |
| CLASSIFICATION | Clinical Nurse Specialist |
| AREA OF SPECIALIZATION | Pediatrics |
| STATUS | Active |
| VA CODE | V100321 |
| X12 CODE | 364SP0200X |
| SPECIALTY CODE | 89 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253458 |
| EFFECTIVE DATE/TIME |
|