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Get GA Delegating Physician Information 2014-2024

EORGIA LICENSE NUMBER __________________________ DEA REGISTRATION NUMBER FIRST NAME MIDDLE NAME Please check, if the delegating physician is a: ____Georgia state employee ____Georgia county employee ____Georgia city employee If you checked any of the boxes above, please submit proof of employment. DEGREE: (MD OR DO) PRACTICE DESCRIPTION AND SPECIALTY AREA: _____________________________________________________________ # OF LOCATIONS- TO INCLUDE SATELLITE SITE(S): PRACTICE ADDRESS WHERE APRN.

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