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Evalidated are required to be identified with NPI in the upper portion of this section; check revalidation box. Section 3.1 - If Yes, Section 3.2 must be completed. See Attached is not acceptable. Section 4B - All association information is required to be completed for all entities/groups that individual is revalidating enrollment with (for each PTAN identified in Section 1A). Section 13 - Include an email address and fax number. Section 15 - Original and.

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