Application Provider – Village Urgent Care & Wellness Center

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First Name *

Last Name *

Address *

Phone Number *

NPI Number *

Medical License Number *

DEA (or input NA) *

Position Applying For *

Email (copy) *

Address (copy) *

Phone Number (copy) *

NPI Number (copy) *

Medical License Number (copy) *

DEA (or input NA) (copy) *

Position Applying For (copy) *

Upload Your CV Here *

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Drivers License *

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Social Security Card *

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Caqh ID

DEA CARD

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Medical License *

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ACLS Card

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BLS Card *

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Voided Check *

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Resume *

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Malpractice form - download form using link, fill it out the re-upload https://westoaksurgentcare.net/site/wp-content/uploads/2025/09/Provider-Application-NFP-Medical-Malpractice-1.pdf *

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Texas Credentialling Package - download form using link, fill it out the re-upload https://westoaksurgentcare.net/site/wp-content/uploads/2025/09/lhl234.pdf *

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https://westoaksurgentcare.net/site/wp-content/uploads/2025/09/lhl234.pdf

Signature: Position: Nurse Practitioner Pay: $75/hr Tax Status: 1099

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