Date *

Application Assistant Information

Name of person who might help applicant fill out portions of the application (ie: office manager, locum contact) *

Phone

Email *

Applicant Information

Application is for

First Name (as it appears/will appear on your professional license) *

Middle Initial

Last Name (as it appears/will appear on your professional license) *

Is this provider currently privileged within WellSpan Health or an employee of WellSpan Physician Group?

Date of Birth *

Employee number

Last 4 digits of provider's SSN *

NPI

CAQH Number Providing this information may expedite processing

Pennsylvania License (You must complete one of these fields)

License # in Pennsylvania

Submitted Pennsylvania license application on

Title *

Primary Supervising/Collaborative Physician (PA/CRNP/CNM Only)

Substitute Supervising/Collaborative Physician)

New Graduate? Yes No

Specialty *

Other, if specialty not shown

Provider Information

Street Address *

City *

State *

Zip Code *

Phone (Cell) *

Phone (Home)

Unique Email for the Provider *

Applicant's communication preference *

Practice Information

Primary Practice Name *

Primary Practice Address *

Office Manager or Best Contact Name *

Office Manager or Best Contact Phone *

Office Manager or Best Contact Email *

Additional Details

Is the applicant currently practicing within a 50-mile radius of a WellSpan health facility? Yes No

Estimated Office Start Date

Estimated Hospital Start Date

Start date must be at least 90 days from the submission of this form and must be either the 2nd or 4th Monday of the month.
If start date is desired less than 90 days, please contact wellspanmedicalstaffservices@wellspan.org

Explanation of credentialing request/Please list any special circumstances