Nominate a Provider Portneuf Quality Alliance

Nominate a Provider

Use this form to request a new provider for the PQA network. Enter as much information as you can.

We will only contact you if we require further details or clarification to determine provider eligibility.

Your Name *

The person making the request

Your Email *

We do not share your information.

Phone Number

(optional)

Please be as thorough as possible when adding the provider's information.

Tax ID #

National Provider Identifier

Name of Practice

Hospital Affiliation

Specialty

Provider Categories

Primary Care Specialists?

Yes

Provider - First Name

Provider - Last Name

Degree/Credentials

Gender

Additional Languages Spoken

Board Certifications

Street Address

City

County

State

Zip Code

Phone Number

Fax Number

Please tell us anything else you know about the provider you are nominating

* Type the numbers you see below