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Honoraria HIV (HIVM/HIVP):
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Last Name:
Suffix:
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Email:
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Always CC AltEmail?
Alternate Email 1:
Alternate Email 2:
Business Phone:
Cell Phone:
Home Phone:
Fax:
Address:
Suite/Unit/Apt.:
City:
State:
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Zip:
Country:
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Additional Information:
Affiliation:
Department:
Title:
2nd Affiliation:
3rd Affiliation:
2nd Title:
Credentials:
Disclosures:
Assistant's Info:
Degree:
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Specialty:
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NABP #:
DOB:
State License #:
State of License:
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NPI #:
IMS #:
Gender:
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Male
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Preferred Contact Method:
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Email
Alternate Email 1
Alternate Email 2
Work Phone
Cell Phone
Fax
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Email
Alternate Email 1
Alternate Email 2
Work Phone
Cell Phone
Fax
Practice Setting:
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Notes:
Alternate Contact Information:
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Alternate Address:
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Administrative Information:
Educator Honoraria HIV:
Educator Honoraria PAH:
Educator Honoraria HEP:
Educator Honoraria SIHD:
Educator Honoraria CF:
Educator Honoraria ILD:
Educator Honoraria NASH:
Educator Honoraria Thrombocytopenia CLD:
Educator Honoraria RA:
Educator Honoraria ITP:
Educator Honoraria HAE:
Educator Honoraria PHILD:
Educator Honoraria HLH:
Educator Honoraria MF:
Educator Honoraria NF1-PN:
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Educator Paperwork Complete?
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