Family Practice Provider Application
Assurance Healthcare & Counseling Center is seeking a family practice provider (physician or nurse practitioner). Please use the form below to submit your application to us directly.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What medical degree do you hold?
*
Please Select
MD
DO
ARNP
PA
Other
What is your medical specialty?
*
When did you graduate your most recent training (residency / NP training / etc.)?
*
Do you currently hold a valid medical license in WA State?
*
Please Select
Yes
Not yet, but very soon
Not yet, but will once a position is offered
No
In what state(s) do you currently hold a medical license?
*
In 300 words or less, tell us your thoughts on the current healthcare system.
*
0/300
In 500 words or less, tell us what has led you to apply for this position.
*
0/500
In 500 words or less, tell us about yourself outside of the medical field.
*
0/500
In 200 words or less, tell us about your ideal practice, patient panel, and work/life balance.
*
0/200
What else would be good for us to know about you?
*
0/500
Upload your CV
*
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