Collaboration Agreement No:
9761
Confirmation No:
9761_5012C0006407
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Urology Clinic and Ambulatory Surgery Center
Facility
Kaiser Permanente
Address
1221 Mercantile Ln
Largo
MD 20874
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