Collaboration Agreement No:
5693
Confirmation No:
5693_2451C0008599
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Private Practice / Outpatient Clinic
Facility
Prince George's County Drug & Alcohol Rehab
Address
3000 Lottsford Vista Rd
Bowie
MD 20721
Is this the location where a copy of your collaboration agreement is on file? YES
A copy (paper or electronic) must be immediately available upon request by the Board.
Section 3 - Advanced Duties and Prescriptive and Dispensing Authority
1.Does this Collaboration Agreement include Advanced Duties?
NO
2. Does this Collaboration Agreement include prescriptive authority?
YES
3. Does this Collaboration Agreement include dispensing authority under a physician's active dispensing permit?
NO