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Get PA DPW Provider Enrollment Base Application 2014-2024

Ate. 13a. Indicate whether the provider operates under a fictitious business/doing-business as (d/b/a) name. 13b. If applicable, enter the statement/permit number and the name. Attach a legible copy of the recorded/stamped fictitious business name statement/permit. 14. Enter your date of birth. 15. Enter your gender. 16. Enter the title/degree you currently hold. 17a. Enter your IRS address. This address is where your 1099 tax documents will be sent. 17b-f. Enter the contact inform.

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