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Physician Assistant Applications
**NOTICE**
In order to comply with federal law, the West Virginia Board of Medicine is obligated to inform each applicant or licensee from whom it requests a Social Security Number that disclosing such number is MANDATORY in order for this Board to comply with the requirements of the federal National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank. If this Board should be required to make a report about one of its applicants or licensees to either of these data banks, it must report that individual’s Social Security Number.
You will find below the applications needed for applying for a license.
ADDTIONAL REQUIREMENT
Criminal History Record Check - Prior to issuance of initial licensure.
Related Information
Forms & Documents
- Physician_Assistant_Practice_Agreement_Form_&_Instructions (734 kb PDF)
- Addtional Instructions for Delegation of MAT (78 kb PDF)
- Appendix A Advanced Procedure Reference List (72 kb PDF)
- Appendix_B_Alternate_Collaborating_Physician_Form (176 kb PDF)
- Notification of Termination of a Practice Agreement 10-17 (156 kb PDF)
- Duplicate Wall License Request (7 kb PDF)
- Name Change Affidavit (53 kb PDF)
- Initial Physician Assistant Licensure Application (303 kb PDF)
- Charitable Exemption Authorization WV PA (117 kb PDF)
- Charitable Exemption Authorization Out of State PA 2018 (123 kb PDF)
- Controlled Substance Dispensing Practitioner Registration Application (177 kb PDF)
Licensure
The West Virginia Board of Medicine is the sole authority for the issuance of licenses to practice medicine and surgery, to practice podiatry, and to practice as a physician assistant in collaboration with MDs and DPMs in the State of West Virginia, and is the regulatory and disciplinary body for medical doctors, podiatric physicians and their physician assistants.
Contact Us
101 Dee Drive
Suite 103
Charleston WV 25311
Phone: (304) 558-2921
Fax: (304) 558-2084
Map: Contact Page
Hours: 8:30 AM - 4:30 PM EST
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