Collaboration Agreement No:
9128
Confirmation No:
9128_4514C0009199
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Facility
Medstar Montgomery Medical Center
Address
18101 Prince Philip Drive
Olney
MD 20832
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