| Name | Value |
|---|---|
| PROVIDER TYPE | Physician Assistants & Advanced Practice Nursing |
| CLASSIFICATION | Nurse Practitioner |
| AREA OF SPECIALIZATION | Pediatrics: Acute Care |
| STATUS | Inactive |
| DATE INACTIVATED | 2005-11-15 00:00:00 |
| VA CODE | V100612 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253323 |
| EFFECTIVE DATE/TIME |
|