Collaboration Agreement No:
9294
Confirmation No:
9294_4649C0007964
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Private Practice / Outpatient Clinic
Address
4701 Sangamore Rd Ste 100 N
Bethesda
MD 20816
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