LOUISIANA STATE BOARD OF MEDICAL EXAMINERS

NOTE TO BOARD COMPLETING THIS FORM: If answer to 1 or 2 is “No”, or 3 through 10 is “Yes”, explain and attach certified copies of pertinent material (i.e., Notice of Hearing, Final Decision, Consent Order/Agreement, etc.). Name: SS#: Louisiana State Board of Medical Examiners. P. O. Box 30250, New Orleans, LA 70190-0250 ................
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