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Get AK 08-4226d 2014-2024

Include the $100 Collaborative Plan fee with this form. Attach a copy of the PA’s current NCCPA certificate. Attach a copy of the PA’s valid DEA registration. Attach a copy of the collaborating physician’s valid DEA registration. Attach a detailed curriculum vitae for the PA, if applicable, for remote site practice (see remote site information below). Mail the completed plan with all attachments to the State Medical Board. PO Box 110806, Juneau AK 99811-0806. ( Keep a complete copy for y.

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