Collaboration Agreement No:
6620
Confirmation No:
6620_3155C0001931
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
MDARNG Military Medical Readiness Clinic
Facility
Military Medical Readiness Clinic
Address
5555 Rue St Lo Drive
Reisterstown
MD 21136
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?
NO
3. Does this Collaboration Agreement include dispensing authority under a physician's active dispensing permit?
NO