University of Kansas Medical Center
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Community Engagement >
Rural Health >
Kansas Locum Tenens >
Faculty Profile Form
Present address (number & street, city, state, zip):
Telephone (office): Telephone (home):
DEA Certificate Number:
DEA Expiration Date:
Time periods available for Locum Tenens:
Time periods not available for Locum Tenens:
List procedures performed:
List practice limitations:
Preferred e-mail address:
(please be specific, i.e: firstname.lastname@example.org)
How did you hear about Kansas Locum Tenens? Please be specific.
To submit, please press
To clear the form and start over, please press
Do you have any questions?
Check out our KLT FAQs.
For more information about how to "Become a Provider" or "Request Service" contact Andrea Ellis at 913-588-1228 or email@example.com.