Join as Provider — FineraTech

Personal Information

Profile Photo

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max 5 MB

First Name *

Last Name *

Email Address *

Phone Number *

Gender

Date of Birth

Professional Profile

Professional Description

Category *

Type / Specialty *

Government-Issued Identification

ID Type *

ID Number *

ID Expiry Date

Issuing State

Issuing Country

ID — Front Image

JPG, PNG, PDF — max 5 MB

ID — Back Image

JPG, PNG, PDF — max 5 MB

Professional License

License Type

License Number

License Expiry Date

Issuing State

Issuing Country

License — Front Image

JPG, PNG, PDF — max 5 MB

License — Back Image

JPG, PNG, PDF — max 5 MB

Practice / Clinic

Select Your Practice *

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Complete the fields below to register your practice.

Practice / Clinic Name

Practice Phone

Street Address

Suite / Apt

City

State

ZIP

Country

Practice Website

Customer Service Contact Name

Business / Customer Service Phone Number

Business / Customer Service Contact Email

Business & Scheduling Information

Supported Services

Metropolitan Area / Locality Served

Additional Provider Information (Optional)

Supported Services (optional)

Metropolitan Area / Locality Served (optional)

NPI Number (optional)

DEA Number (optional)

Supervising Physician Name (optional — required for PAs)

Supervising Physician License # (optional)

Supervising Physician NPI (optional)

Malpractice Insurance Provider (optional)

Malpractice Policy Number (optional)

Hospital Affiliations (optional)

Languages Spoken (optional)

Years of Experience (optional)

Accepts New Patients (optional)

Telehealth Available (optional)

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