Collaboration Agreement No:
4081
Confirmation No:
4081_2003C0008586
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Private Practice / Outpatient Clinic
Facility
DSF Cosmetic and Medical Dermatology
Address
68 Thomas Johnson Dr Suite C
Frederick
MD 21702-4901
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