Collaboration Agreement No:
5615
Confirmation No:
5615_2390C0003870
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Urgent Care
Facility
ExpressCare Urgent Care Center Forest Hill
Address
2006 Rock Spring Road
Forest Hill
MD 21050
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. Sitta Baby Gombeh-Alie | License No: D0090155