knownwell - Physician

Please select your clinical license type/credentials:✱
- MD
- DO
- PA
- NP
- RN
- Other
Please select the states in which you currently hold an active license:✱
- AK - Alaska
- AL – Alabama
- AR – Arkansas
- AZ – Arizona
- CA – California
- CO – Colorado
- CT – Connecticut
- DC – Washington, D.C.
- DE – Delaware
- FL – Florida
- GA – Georgia
- HI – Hawaii
- IA – Iowa
- ID – Idaho
- IL – Illinois
- IN – Indiana
- KS – Kansas
- KY – Kentucky
- LA – Louisiana
- MA – Massachusetts
- MD – Maryland
- ME – Maine
- MI – Michigan
- MN – Minnesota
- MO – Missouri
- MS – Mississippi
- MT – Montana
- NC – North Carolina
- ND – North Dakota
- NE – Nebraska
- NH – New Hampshire
- NJ – New Jersey
- NM – New Mexico
- NV – Nevada
- NY – New York
- OH – Ohio
- OK – Oklahoma
- OR – Oregon
- PA – Pennsylvania
- RI – Rhode Island
- SC – South Carolina
- SD – South Dakota
- TN – Tennessee
- TX – Texas
- UT – Utah
- VA – Virginia
- VT – Vermont
- WA – Washington
- WI – Wisconsin
- WV – West Virginia
- WY – Wyoming
Are you willing and eligible to obtain additional licensure if needed?✱
- Yes
- No
Please provide your National Provider Identifier:✱
Do you have any preferences or restrictions for your weekly schedule?✱

Are you currently authorized to work in the United States?✱
- Yes
- No
Do you now, or will you in the future, require sponsorship for employment visa status to work in the United States?✱
- Yes
- No

Physician