Collaboration Agreement No:
7574
Confirmation No:
7574_3354C0009265
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Private Practice / Outpatient Clinic
Facility
Medstar Shah Medical Group Lanham
Address
9811 Greenbelt Rd Suite 104
Lanham
MD 20706-2215
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?
YES
Physician's Name: Dr. Rodney L Ellis | License No: D0021326