IASIS Technologies - Provider Information

Provider Information

First Name *

Last Name *

Personal Cell (For IASIS only, to communication directly with you) *

Personal Email (For IASIS only, to communication directly with you) *

Preferred Communication Method

Email

Phone

Profession *

Choose 1

Please Check One *

IASIS Certified Practitioner (ICP)

IASIS Certified Technician (ICT)

IASIS Certified Mentor (ICM)

Patient Access Representative ONLY

Provisional Under

Business Info

Name of Business/Practice

Office Phone Number

Website

Business Address

Address

City

State

Postal code

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IASIS Contact Information

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Please upload a copy of current professional license or full and clear photo of it below: *

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