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Please list all educational facilities in chronological order, beginning with high school.
Education
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Is this school foreign to the U.S.?*
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Did you attend a Fifth Pathway?
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Were clerkships complete in your country of graduation?
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Were clerkships completed in the U.S.?
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if so, please fax or mail a list of the clerkships that were performed in the U.S.
ECFMG Number
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List all licensing exams taken in the US.
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NPI
List all US medical licenses that have ever been issued to you.
Licence
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License type*
Has any action(s) been taken against your license?
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Please Explain
No Are you registered with the DEA?
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DEA registration number
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List all US Board Certifications that have ever been awarded to you.
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Date certified*
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Date recertified*
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Employment
List in order of chronology from date of completion of postgraduate training, to present, all employment, including staff affiliations.
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Any unusual circumstances? (e.g. time off, disciplinary action, retaking classes)*
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Malpractice
List all malpractice cases that have ever been filed against you.
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Please provide a brief description of the complaint, plaintiff name, case number, policy number, and outcome of the case. Also include the county where the case was filed.

Notes
I understand that the following questions, if answered incorrectly, may result in adverse actions by the medical board up to and including denial of licensure.*
- I Agree
Have you ever been the subject of any disciplinary or adverse action in medical school, postgraduate training, or during your professional career? If yes, please explain below.*
- Yes
- No
Have you ever been named in a malpractice suit? Provide dates and basic details below. We will let you know if the board requires further information.*
- Yes
- No
Have you ever been arrested or charged with a felony or misdemeanor, including DUI or DWI? If yes, please explain below.*
- Yes
- No

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Medical Licensing – Reimagined.

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["title"]=> string(23) "Medical License Renewal" ["target"]=> string(0) "" ["attr_title"]=> string(0) "" ["description"]=> string(0) "" ["classes"]=> array(4) { [0]=> string(0) "" [1]=> string(9) "menu-item" [2]=> string(24) "menu-item-type-post_type" [3]=> string(21) "menu-item-object-page" } ["xfn"]=> string(0) "" ["current"]=> bool(false) ["current_item_ancestor"]=> bool(false) ["current_item_parent"]=> bool(false) } object(WP_Post)#6854 (40) { ["ID"]=> int(6226) ["post_author"]=> string(2) "40" ["post_date"]=> string(19) "2020-03-15 16:29:18" ["post_date_gmt"]=> string(19) "2020-03-15 16:29:18" ["post_content"]=> string(1) " " ["post_title"]=> string(0) "" ["post_excerpt"]=> string(0) "" ["post_status"]=> string(7) "publish" ["comment_status"]=> string(6) "closed" ["ping_status"]=> string(6) "closed" ["post_password"]=> string(0) "" ["post_name"]=> string(4) "6226" ["to_ping"]=> string(0) "" ["pinged"]=> string(0) "" ["post_modified"]=> string(19) "2020-03-15 16:29:35" ["post_modified_gmt"]=> string(19) "2020-03-15 16:29:35" ["post_content_filtered"]=> string(0) "" ["post_parent"]=> int(0) ["guid"]=> string(36) "https://medicallicensing.com/?p=6226" ["menu_order"]=> int(5) ["post_type"]=> string(13) "nav_menu_item" ["post_mime_type"]=> string(0) "" ["comment_count"]=> string(1) "0" ["filter"]=> string(3) "raw" ["db_id"]=> int(6226) ["menu_item_parent"]=> string(1) "0" ["object_id"]=> string(4) "5075" ["object"]=> string(4) "page" ["type"]=> string(9) "post_type" ["type_label"]=> string(4) "Page" ["url"]=> string(49) "https://medicallicensing.com/hospital-privileges/" ["title"]=> string(19) "Hospital Privileges" ["target"]=> string(0) "" ["attr_title"]=> string(0) "" ["description"]=> string(0) "" ["classes"]=> array(4) { [0]=> string(0) "" [1]=> string(9) "menu-item" [2]=> string(24) "menu-item-type-post_type" [3]=> string(21) "menu-item-object-page" } ["xfn"]=> string(0) "" ["current"]=> bool(false) ["current_item_ancestor"]=> bool(false) ["current_item_parent"]=> bool(false) } object(WP_Post)#6855 (40) { ["ID"]=> int(6227) ["post_author"]=> string(2) "40" ["post_date"]=> string(19) "2020-03-15 16:29:18" ["post_date_gmt"]=> string(19) "2020-03-15 16:29:18" ["post_content"]=> string(1) " " ["post_title"]=> string(0) "" ["post_excerpt"]=> string(0) "" ["post_status"]=> string(7) "publish" ["comment_status"]=> string(6) "closed" ["ping_status"]=> string(6) "closed" ["post_password"]=> string(0) "" ["post_name"]=> string(4) "6227" ["to_ping"]=> string(0) "" ["pinged"]=> string(0) "" ["post_modified"]=> string(19) "2020-03-15 16:29:35" ["post_modified_gmt"]=> string(19) "2020-03-15 16:29:35" ["post_content_filtered"]=> string(0) "" ["post_parent"]=> int(0) ["guid"]=> string(36) "https://medicallicensing.com/?p=6227" ["menu_order"]=> int(6) ["post_type"]=> string(13) "nav_menu_item" ["post_mime_type"]=> string(0) "" ["comment_count"]=> string(1) "0" ["filter"]=> string(3) "raw" ["db_id"]=> int(6227) ["menu_item_parent"]=> string(1) "0" ["object_id"]=> string(4) "5078" ["object"]=> string(4) "page" ["type"]=> string(9) "post_type" ["type_label"]=> string(4) "Page" ["url"]=> string(42) "https://medicallicensing.com/telemedicine/" ["title"]=> string(22) "Telemedicine Licensing" ["target"]=> string(0) "" ["attr_title"]=> string(0) "" ["description"]=> string(0) "" ["classes"]=> array(4) { [0]=> string(0) "" [1]=> string(9) "menu-item" [2]=> string(24) "menu-item-type-post_type" [3]=> string(21) "menu-item-object-page" } ["xfn"]=> string(0) "" ["current"]=> bool(false) ["current_item_ancestor"]=> bool(false) ["current_item_parent"]=> bool(false) } object(WP_Post)#6774 (40) { ["ID"]=> int(6228) ["post_author"]=> string(2) "40" ["post_date"]=> string(19) "2020-03-15 16:29:18" ["post_date_gmt"]=> string(19) "2020-03-15 16:29:18" ["post_content"]=> string(1) " " ["post_title"]=> string(0) "" ["post_excerpt"]=> string(0) "" ["post_status"]=> string(7) "publish" ["comment_status"]=> string(6) "closed" ["ping_status"]=> string(6) "closed" ["post_password"]=> string(0) "" ["post_name"]=> string(4) "6228" ["to_ping"]=> string(0) "" ["pinged"]=> string(0) "" ["post_modified"]=> string(19) "2020-03-15 16:29:35" ["post_modified_gmt"]=> string(19) "2020-03-15 16:29:35" ["post_content_filtered"]=> string(0) "" ["post_parent"]=> int(0) ["guid"]=> string(36) "https://medicallicensing.com/?p=6228" ["menu_order"]=> int(7) ["post_type"]=> string(13) "nav_menu_item" ["post_mime_type"]=> string(0) "" ["comment_count"]=> string(1) "0" ["filter"]=> string(3) "raw" ["db_id"]=> int(6228) ["menu_item_parent"]=> string(1) "0" ["object_id"]=> string(4) "5081" ["object"]=> string(4) "page" ["type"]=> string(9) "post_type" ["type_label"]=> string(4) "Page" ["url"]=> string(43) "https://medicallicensing.com/medical-staff/" ["title"]=> string(36) "Medical Staff Credentialing Services" ["target"]=> string(0) "" ["attr_title"]=> string(0) "" ["description"]=> string(0) "" ["classes"]=> array(4) { [0]=> string(0) "" [1]=> string(9) "menu-item" [2]=> string(24) "menu-item-type-post_type" [3]=> string(21) "menu-item-object-page" } ["xfn"]=> string(0) "" ["current"]=> bool(false) ["current_item_ancestor"]=> bool(false) ["current_item_parent"]=> bool(false) } Physician Assistant Licensing Nurse Licensing Medical Credentialing Services Medical License Renewal Hospital Privileges Telemedicine Licensing Medical Staff Credentialing Services

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