Providers Add Provider

Add Provider

Create, validate, and onboard a provider across clinical, operational, billing, access, and compliance workflows.

Profile Completion

Last saved: Just now

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Onboarding Steps

Basic Information

Primary provider details and professional information

Required

Provider Type *

First Name *

Middle Name

Last Name *

Display Name *

Suffix

Professional Title

Department

Primary Specialty *

Secondary Specialties

Preventive Care Chronic Care Management

Employment Type *

Start Date *

Status

Gender

Pronouns

Provider Photo

Click to upload photo

JPG, PNG up to 5MB

Biography / Professional Summary

0/500 characters

Care Focus & Tags

Duplicate Provider Warning

No potential duplicates found based on name and NPI screening.

Identity & Verification

National identifiers, contact information, and verification status

NPI Type 1 (Individual) *

Verified

NPI Type 2 (Organization)

CAQH ID

PECOS Enrollment

SSN (Last 4)

Date of Birth

Nationality

Personal Email

Professional Email *

Mobile Phone

Addresses

Primary

Home Address

4521 N Central Ave
Phoenix, AZ 85012

Verified via NPI

Mailing

Mailing Address

PO Box 8712
Phoenix, AZ 85066

Pending verification

Add Address

Identity Verification Status

NPI Registry

Verified

CAQH ProView

Linked

PECOS

Pending Review

Credentials & Licensure

Medical licenses, DEA, certifications, and education

Medical Licenses

2 active licenses

State	License Number	Issue Date	Expiration	Status	Actions
Arizona	ME-123456	06/15/2018	06/30/2025 Expiring soon	Active
California	A-987654	03/10/2020	09/30/2026	Active

DEA Registration

BR4927816 • Expires: 12/31/2025

Valid for CSII-V Arizona, California

Active

Board Certifications

American Board of Family Medicine

Family Medicine

Active

Certification Date: 07/15/2016

MOC Due: 12/31/2025

Certificate #: ABFM-123456

Add Certification

Medical School

University of Arizona College of Medicine

MD • Class of 2014

Residency

Banner - University Medical Center

Family Medicine • 2014-2017

Fellowship

Preventive Medicine Fellowship

Johns Hopkins • 2017-2018

Malpractice Insurance

Current

Carrier

Medical Protective

Policy Number

MP-987654321

Coverage

$1M/$3M

Expiration

12/31/2025