Faculty Profile Form

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


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

Telephone (office):

Telephone (home):

License number:

Board certified:

Yes No

Board eligible:

Yes No


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:




Preferred e-mail address:

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

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

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To clear the form and start over, please press

Last modified: Jul 29, 2013

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