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Get and Sign Georgia Delegating Physician 2014-2022 Form

Get and Sign Georgia Delegating Physician 2014-2022 Form

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Employment. DEGREE: (MD OR DO) PRACTICE DESCRIPTION AND SPECIALTY AREA: _____________________________________________________________ # OF LOCATIONS- TO INCLUDE SATELLITE SITE(S): PRACTICE ADDRESS WHERE APRN IS PRACTICING UNDER THIS PROTOCOL AGREEMENT: (If more than one location, list the primary practice location for the APRN) STREET NUMBER STREET NAME SUITE # CITY STATE ZIP CODE (AREA CODE) PHONE NUMBER (AREA CODE) FAX NUMBER (OPTIONAL) COUNTY ADVANCED PRACTICE REGISTERED NURSE...
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