| Name | Value |
|---|---|
| PROVIDER TYPE | Technologists, Technicians & Other Technical Service Providers |
| CLASSIFICATION | Specialist/Technologist, Other |
| AREA OF SPECIALIZATION | Nephrology |
| STATUS | Active |
| VA CODE | V151003 |
| X12 CODE | 246ZN0300X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5255675 |
| EFFECTIVE DATE/TIME |
|