01/20/2012 11:20 FAX $02 647 0406 GYN ONCOLOGY f@oo1/001 STATE OF VERMONT - DOARD OF MEDICAL-PRACTICE a 108 CHERRY STREET \ BURLINGTON, VT 03401 “\ toon esa 40 SECONDARY SUPERVISING PHYSICIAN APPLICATION 7 Please print. Incomplete applications will be retumed. Attach additional sheets as needed. sees sean Awe st) (First) t ‘Middle a 7 ce Vee ee oone 8 Mailing Address \ 4 rely LAwe (Office Name) aa ‘Gueen 7 \) Waster git asa ( go2\ SQ hee (City/State) (Zip Code) Celeptione Number) Vermont License #: A = 800 KF S4 Hospital(s) where you have privileges: Hospitals) Location Specialty af SEZ ee ie G {oyna List all physician’s assistants names and addresses you currently supervise: SERS STA OER CERTIFICATE OF SECONDARY SUPERVISING PHYSICIAN {Uneceby eectify that, in sezordance with 26.VSA, Chapter 31, I shall be legally reeponsibt for all medical activites of Ses CA WPA. only when the primary supervising physician is unavailable and only when consulted by the aforesaid Physician Assistant. [further certify thatthe protocol outlining the scope of practice, atached to this application, docs not exceed the normal limits of my practice and thet in accordance with 26 VSA, Chapter 31, Section 1741, the use of physician asisant hes been posted "further cei tha have ead the stares and Board rules governing phtician sssstants } isle Kee Qa way Busy ‘Gieranare of Secondny Supervising Physician) ~ \ JAN 23 2012 ‘Vermont Department of Health — Board of Medical Practice 2012-2014 Physician Assistant Licensure Renewal Page 15 0f 1901/20/2012 15:18 FAX 802 847 0496 GEN ONCOLOGY : oon STATE OF VERMONT - BOARD OF MEDICAL PRACTICE, 108 CHERRY STREET mt gheme Shh BURLINGTON, VI 05401 S55. Snag (G02) 657-4220 SECONDARY SUPERVISING PHYSICIAN APPLICATION Please print. Incomplete applications will be retumed. Attach additional sheets as needed, ‘Name in full vullo tl Hshal (Last) First aide) Mailing Address 21 Beaumont ve Gen Oa0iD (Office Name) OW Awe TDA Nett §02-056-Baab City/State) Gip Codey (Telephone Number) ‘Vermont License # O42" 6.99 50 Hospital(s) where you mie privileges: Hospital(s) Location Specialty EABCS List all physician's assistants names and addresses you currently supervise: Se dwhuie Seals CERTIFICATE OF SECONDARY SUPERVISING PHYSICIAN hereby certify tha, in aceordance with 26 VSA, Chapter 31, Eshall be legally responsible forall medical ativiies of eghante S\eu P.A, only when the primary supervising physician is unavailable and only when consulted by the Aferesad Physician Acvisant, 1 Farther cert thatthe protocol cutning te scope of practic, attached to ths application, dors not exceed the normal limits of my practice and that in accordance with 26 VSA, Chapter 31, Section 1741, the use of a physician assistent has been posted. | further certify that Ihave read the statutes and Bowes sovecning physician Fa0-1 Mihalis WY Date) = Mel ELIA saat fi 4 JAN 25 2012 \Vernont Department of Health ~ Board of Medical Practice ~ 2012-2014 Physioian Assistant Licensure Renewal Page 15 of 19STATE OF VERMONT - BOARD OF MEDICAL PRACTICE 108 CHERRY STREE BURLINGTON, VT 05401 (802) 657-4220, SECONDARY SUPERVISING PHYSICIAN APPLICATION Please print. Incomplete applications will be returned. Attach additional sheets as needed, Name in full Qracte _ Soli peu (ast) Gist) (Middle) Mailing Address — Necmant Gorecsiony (Office Name) eae NVA Tboituston Cod Soke Woe (Street) Sok Qociinges VE D545 : &IWYIAY- HEE (City/State) (Zip Code) (Telephone Number) Vermont License #: OY (10/0 FY / Hospital(s) where you have privileges: Hospital(s) Location Specialty List all physician’s assistants names and addresses you currently supervise: CERTIFICATE OF SECONDARY SUPERVISING PHYSICIAN "ery certify that, in angordance wih 26 VSA, Chapter 31,1 shal be legally responsible forall medical activities of Foca StS She4s__,P-A oly when the primary supervising pysican is unavalable and only hen consulted by the aforesaid Physician Assn [rte cert thatthe protocol ouining the scope of practic, aahed fo thoy henton nea exceed the nomal nits of my practice aud that in accordance with 26 VSA, Chaper 3, Section 1741 the te ce voto ve cent hes been posted. | further certify that I have read the statutes and Board rules governing physician assistants, Giefriir Se ial a) ‘Giovate of Secondary Supeniaing Pian) ‘Vermont Department of Health — Board of Medical Practice 2012-2014 Physician Assistant Licensure Renewal Pron 8a0 10)