Last Name* Req'd	First Name* Req'd	Middle Initial
Provider Initials * Req'd	Specialty Dental Family Practice Nurse Practioner OB Optometrist Pediatric Podiatry Psychiatry Registered Nurse Unknown	Degrees/Credentials * Req'd
DEA Number * Optional	DEA Active Date * Optional	DEA Term Date * Optional
Mailing Address * Req'd	City * Req'd	State * Req'd
Zip Code * Req'd	Fax No. * Req'd
Start Date* Req'd	Specialty * Req'd	ePrescribing Yes No
Primary Service Location * Req'd Select Facility Adult Day CFPC-A CFPC-B CFPC-C CFPC-CPSP CFPC-D CFPC-E CFPC-MentalHealth CFPC-Tab CLinic Elsie - Medical Elsie - Mental Health Humboldt St. Clinic Junior College Lombardi - CPSP Lombardi - Medical Lombardi - Mental Health Memorial Hospital Petaluma Valley Hospital Roseland - Medical Roseland - Mental Health SR Homeless Clinic Sutter Hospital Turning Point	Male * Req'd Female * Req'd	FTE * Req'd (estimate .05 increments)

Provider Tax ID : * Req'd		Accept Clearinghouse? Yes No
NPI * Req'd		Accept ePrescribing? Yes No
State License * Optional	License Active Date * Optional	License Term Date * Optional

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