Collaboration Agreement No:
5869
Confirmation No:
5869_2582C0003294
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Private Practice / Outpatient Clinic
Address
1 E. Chase St Suite #1117
Baltimore
MD 21202
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