Faculty Profile Form

Name (first, M.I., last, maiden):

Department:

Present address (number & street, city, state, zip):

Telephone (office):


Telephone (home):

License number:

Board certified:

Yes No

Board eligible:

Yes No

Obstetrics:

Yes No

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:

 

Comments:

 

Preferred e-mail address:

(please be specific, i.e: tsmith@kumc.edu)

How did you hear about Kansas Locum Tenens? Please be specific.

To submit, please press

To clear the form and start over, please press

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Questions?

Check out our  KLT FAQ for answers.

KLT FAQ

For more information about how to "Become a Provider" or "Request Coverage" contact Andrea Ellis at 913-588-1228 or aellis2@kumc.edu.


Request Coverage

Register as a KLT Provider

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