Registration Form

We will need some information to get started. Please complete the form below and advise how you would like to be contacted.

Provider Candidate Registration

Last Name:

First Name:

M.I.:

Title:

Degree:

License #:

State:

NPI #: 
 

Address:

City:

State:

Zip:

Phone:

Fax:

E-mail Address:

Additional Languages :

Specialty preference:

Please indicate your contact method preference.

E-mail

Telephone

Fax

U.S. Mail

What services may we help you with?

What is your work status?

Request a locum tenens assignment

I am Board Certified

Information about  pa-locumtenens.net

I am Board Eligible

Information about assistance with CV 

I am eligible to work in the United States.

What is your availability?

Single Shifts

2 - 15 days

15 - 30+ days

Thank you for choosing Physician Associates Locum Tenens.
We will be in contact with you as soon as possible.

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Physician Associates Locum Tenens
Providing Mid-level Interim Medical Professional Services

PO Box 513
Arroyo Grande, CA 93421-0513
Phone: (805) 929-2015 or (805) 440-1881
E-mail: palt@charter.net

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