Collaboration Agreement No:
8502
Confirmation No:
8502_4055C0003707
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Private Practice / Outpatient Clinic
Facility
Lakeside Med LLC dba Mason-Dixon Mobile Medicine
Address
723 N Market St #207
Frederick
MD 21701
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