| Name | Value |
|---|---|
| PROVIDER TYPE | Physician Assistants & Advanced Practice Nursing |
| CLASSIFICATION | Midwife, Certified |
| STATUS | Inactive |
| DATE INACTIVATED | 2002-12-20 00:00:00 |
| VA CODE | V100400 |
| X12 CODE | 366B00000N |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253335 |
| EFFECTIVE DATE/TIME |
|