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Get OR Practitioner Credentialing Application 2012-2024

_____________________________ VII. PRACTICE CALL COVERAGE NAME: Please provide the name and specialty of those practitioners who provide care for your patients when you are unavailable. SPECIALTY: 1. 2. 3. 4. 5. VIII. UNDERGRADUATE EDUCATION Please attach additional sheets, if necessary. Complete School Name: Degree Received: City: State: IX. GRADUATE EDUCATION Course of Study or Major: Please attach additional sheets, if necessary. Complete School Name: Degree Received: City.

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