Collaboration Agreement No:
6138
Confirmation No:
6138_2783C0006542
Section 1 - Physician Assistant Information
Confidential Information redacted.
Section 2 - Primary Practice Setting & Location:
Practice Type:
Urgent Care-Patient First
Facility
Patient First: UC in White Marsh
Address
4924 Campbell Boulevard, Suite 125
White Marsh
MD 21236
Is this the location where a copy of your collaboration agreement is on file? NO
A copy (paper or electronic) must be immediately available upon request by the Board.
Location: Patient First Admin Office, 5000 Cox Road, Glen Allen, VA 23060. Electronic copy available
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. Dani Sarkis Boulattouf | License No: D0073254