MEMA
Administrative Office:
PO Box 30756
Charlotte, NC 28230-0756
Phone: (704) 377-2424
Fax: (704) 377-2687

Mail Payments To:
PO Box 601504
Charlotte, NC 28260-1504


For Billing Questions or to get a copy of your Bill
Call: (877) 713-7612

     Mid-Atlantic Emergency Medical Associates > Practice Opportunities/Recruitment >

     Submit Your CV


Physician Online Application

Advance Practice Provider Online Application

Midlevel Provider Online Application
Click here to send your CV as a .doc, .txt, .wpd, or .pdf file, or fill in the fields below and click Submit at the bottom of the form.

Personal Information (Mandatory)
First Name
Middle name
Last Name
E-mail Address
Home Phone
Cell Phone
Home Address
City
State
ZIP
Mailing Address
City
State
ZIP

Education
Undergraduate
Major/Degree
Attended from(mo/yr)   to  
PA or NP Program
Degree
Attended from(mo/yr)   to  
Are you Board Certified? yes no
Are you Board Prepared? yes no
By what Boards?
Licenses/Certifications
If not currently licensed, have you applied for an NC license? yes no

Experience
Experience
When do you wish to relocate?
How did you learn about MEMA?


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