Company Last Name * First Name * MI * Other Last Name Known By * Employee number National Provider Identifier Number Degree Position Employment Group Work Phone Cell Phone Other Phone Fax E-Mail * Initial Credential Date Re-Credential Due Date Peer Review Due Date Basic Life Support Certification Expires Advanced Cardiovascular Life Support Expires Partner Certification BOP USMS/ICE California Ohic Other Specify State Licensure State License number Expiration Date License Restrictions State State State State License number License number License number License number Expiration Date Expiration Date Expiration Date Expiration Date License Restrictions License Restrictions License Restrictions License Restrictions Controlled Substance State State State State State License number License number License number License number License number Expiration Date Expiration Date Expiration Date Expiration Date Expiration Date Assigned Sites Site Site Site Site Site Date Date Date Date Date DEA DEA Number DEA Number DEA Number DEA Number DEA Number Expiration Date Expiration Date Expiration Date Expiration Date Expiration Date
