Skip to content
Diagnostechs
Diagnsotechs
PROVIDER PORTAL
BECOME A PROVIDER
0
Cart
Search for:
Search
BECOME A PROVIDER
Home
BECOME A PROVIDER
Become A Provider
Please enable JavaScript in your browser to complete this form.
Clinic / Group
*
Name
*
First
Last
Credentials
ND
NMD
MD
...
Specialty
Cardiology
Dermatology
Hematology
...
License
*
NPI
License Expiry
*
License Country
*
License State
*
Application Filled Out By:
*
Email
*
Certification
*
Yes
No
I Don't Know
I certify that it is within my scope of practice and interpret laboratory tests according to the regulation set forth by my state for my license.
I AM A STUDENT
Please Note
*
Fax
Email
A copy of your professional license/certificate must be sent to Diagnostechs for verification via fax (425-656-2871 or email (accounts@diagnostechs.com). Please indicate which method of transmittal you will use:
Submit
X