| Name | Value |
|---|---|
| PROVIDER TYPE | Physicians (Other Roles) |
| CLASSIFICATION | Physician/Osteopath (Other Roles) |
| STATUS | Inactive |
| DATE INACTIVATED | 2005-11-15 00:00:00 |
| VA CODE | V160100 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5254979 |
| EFFECTIVE DATE/TIME |
|